Maintaining board certification: Stop with the patient surveys

It’s one thing to ask a doctor to stay current on his knowledge, it’s quite another to insist he survey his patients for a private enterprise, especially if that survey represents unvetted independent research.

Recently, a colleague of mine was attempting to maintain his board certification credential with the American Board of Internal Medicine (ABIM) and signed up for the ABIM’s requirement for a practice improvement module worth a required 20 points of 100 total required before he could sit for his specialty board re-certification examination.  For his module, he optimistically chose to offer a survey created by the ABIM to his patients, receive feedback on how he did on the survey, then repeat the survey to a later set of patients to show improvement of care.  In return for his considerable efforts, he would be granted his required points from the ABIM so he could quality to sit for his specialty recertification examination.

Here is an exact copy of the survey my colleague was sent in its entirety.   He received a packet of 70 of these surveys from the ABIM, neatly shrink-wrapped, to distribute to his patients.

What could go wrong?

First, imagine the time and work involved to distribute these surveys. Whether he provided the survey to his patients himself or he tasked others to do so, what lab result was not reviewed or phone call not answered as a result?  We can only speculate.

Second, informed consent about the true nature of this survey was not obtained from patients nor my colleague.  Rather, my colleague was coerced into purchasing the survey because he’s might not be able to continue practicing medicine unless he complies.  Informed consent would suggest that the doctor and his patients are informed of potential harms or risks involved with the collection of such survey data.

For the patient: What might their responses mean for their doctor’s ability to practice medicine?  How might the working relationship with their doctor be degraded or the trust he has in them be compromised?

For the doctor: How are the data collected on the non-secure website protected, how will they be used against him?  Will they be used for future health care policy development or sold to third parties?

I have no doubt that many will see this survey collection as a benign attempt to truly improve a physician’s practice or an opportunity to empower patients with an means of changing physician behavior.  But I suspect these same people never consider the potential negative consequences of such a survey.  The very idea that this survey is a destructive intrusion into the doctor-patient relationship is a foreign concept to its designers.  We can only imagine the moral outrage and disavowal that will arise in the halls of ABIM with such an assessment.  Yet like a bull in a china shop, the collection of anonymous survey data completely disrupts one of the most tenuous and vulnerable relationships in medicine.  It ignores the vulnerable, highly-charged and often emotional circumstances that accompany any visit to a doctor’s office while rendering valid concerns a patient might have about their experience into the muddied waters of anonymous data aggregation.

Also, this unscientific research survey contains a host of dependent variables like age, race and self-assessments of general health status and mental illness.  Self-assessments make a mockery of non-biased data collection, yet the destructive assumptions made throughout the survey are clear: Doctors should have unlimited time, provide unlimited access, and perfect manners toward patients without regard to forces (such as this ABIM survey) that increasingly pull them from what they yearn to do: care for their fellow man, woman or child.   This lack of concern with scientific validity and objectivity  leaves the end game of any particular individual or group findings only left to the imagination.

If we are going to investigate whether an individual doctor’s behavior reflects an age/education/gender/race bias toward their patients (see questions 42 through 46), this is a serious question, deserving of the doctor’s consent, and requiring scientific validity far past that of correlational survey data on an n of 70 patients. The possible end result or accusation is far too damning.  Or haven’t the ABIM committee members thought of that? But we shouldn’t worry: Patient bias/irrationality/emotionalism is controlled for by question 41 — where the patient provides us with an assessment of his overall mental health.

If doctor’s are subjecting themselves to this kind of scrutiny, shouldn’t they (and their patients) know how it will be used? Whether aggregated or individual data, this kind of helter-skelter approach is surely designed to lead to progressive quality initiatives to adjust doctor’s behavior whether findings are valid or not. We are participating in the first step of yet another new initiative in micro-managing and control of the already besieged doctor.

The intrusion of this survey into the sanctity of the doctor-patient relationship by an independent and non-accountable non-profit organization that ignores sound research and ethical principles should be stopped.  It’s negative consequences far outweigh any benefit to patients.

In a recent survey of their membership of over 4000 cardiologists nationwide, the American College of Cardiology found that nearly a third of their respondents indicated that the changes imposed by the ABIM’s subversive recertification process (that includes these patient surveys as one tool) will affect their future career plans and will likely accelerate their decisions, such as early retirement, part-time work, or transition to non-clinical work.  Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement is a likely outcome.  Exactly how will such a survey help patients already struggling to access care?  Is ABIM responsible for the repercussions of their physician bullying?

I know this is a time of multiple instances of moral outrage and demoralization for physicians.  But I would ask that you take that outrage and forward this survey to colleagues.  I would also ask that you I contact your local professional subspecialty organizations, state licensure boards, and appropriate members of Congress to insist on an immediate moratorium to the American Board of Medical Specialties/American Board of Internal Medicine maintenance of certification process as it currently exists.

Believe me, this discussion is ongoing and far from over.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Dr. Drake Ramoray

    AACE recently wrote a formal letter of complaint to the ABIM. I too encourage other docs work through their professional societies to make this crazy maintenance of certification crap stop.

    • James O’Brien, M.D.

      And either support AAPS’ lawsuit or join AAPS:

      http://www.aapsonline.org/index.php/site/article/aaps_takes_moc_to_court/

      The good news is these efforts seem to be working, but slowly. In my latest quarterly email, the American Board of Psychiatry and Neurology was backing off a bit.

      I have no objection to CME credit documentation and a test, but the rest of this nonsense is an expensive beta test experiment and a shakedown.

      • Dr. Drake Ramoray

        Will look into it. Saw you mentioning on another thread but was only skimming comments that weren’t replies to me.

  • LeoHolmMD

    Thank you Dr. Wes. My recent experience with the ABFM version was both expensive and worthless. It is good to hear the clatter getting louder. These legacy organizations can either be accountable to the profession…or they can go away. Unlike so many issues we face these days, this is one we can put a stop to.

  • JR

    That is a horribly written survey. I don’t even know how to begin with how horrible it is. And they definitely shouldn’t be used to maintain license. It seems like they have no way to judge or evaluate a doctor’s ability to do their job so they are using these as a poor substitute?

    I wouldn’t answer it myself because as a patient, I don’t want to provide information they ask in some of the questions.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Unfortunately, this is basically the acclaimed CG-CAHPS survey (with minor adjustments) which is considered the gold standard in the “industry” and it is maintained by AHRQ and administered by large vendors at huge costs to practices.
      ttps://cahps.ahrq.gov/surveys-guidance/cg/instructions/index.html

      • JR

        I think surveys being used by large groups (like hospitals) to help pinpoint where they are doing good, where they need to improve, etc, is very useful.

        I don’t think they are as useful if you try to tie that data to one individual. I might be unhappy that when I was in the hsopital, I was freezing and asked for a blanket, the (nurse? resident? I don’t know?) rolled his eyes at me and brought me one, and then there was a charge for the blanket on the bill to boot!

        That has nothing to do with the doctor on my discharge papers who I never actually met. I would hope that whoever is officially responsible for me would at least meet me, but that’s a problem with the hospital and the way it’s set up not that specific physician.

  • EmilyAnon

    I find those patient surveys useless. There should be a line or 2 after each question for the chance to qualify the answer if needed. For example, question 33 of the survey you link to, asking if the doctor gave adequate pain medication after surgery. After one of my abdominal surgeries, I would have answered yes, *but* that it only worked for 3 hours and it took another 6 hours to get the hospital nurses to address the excruciating pain that followed. A visiting friend became so concerned that she called Pain Management and complained that I was in distress and wasn’t getting any relief after many requests. In 5 minutes a nursing supervisor hurried in my room and gave me the medication I needed. What choice on question 33 should I have circled to reflect this incident. If I had even bothered with the survey, I would have chosen option 5 – “skip this question”. The first 2 options wouldn’t apply, and the next 2 would have been unfair to the doctor. So, what would have been learned from this.

  • ninguem

    I wonder if the medical director of the Joliet State Prison has to survey his patient satisfaction to maintain certification?

    • SteveCaley

      Actually, this Board feedback method may be disrupting and crossing wires with the Federal PLRA Act that guarantees incarcerated persons that the inmate grievance feedback will be properly presented and accessible to Federal courts and authorities. The Boards may be obligated to disclose any inmate physician evaluations to the Department of Justice for their recordkeeping on prison medical matters. Otherwise, it may deprive inmates of appeal rights on civil rights matters.

      • ninguem

        Now I wonder if the pathologists have to dig up their patients for a satisfaction survey.

  • Thomas D Guastavino

    I read the questionnaire. This is a joke, right?

    • Wes Fisher

      No, it is not. Not at all.

      • Thomas D Guastavino

        Wow. I dont know whats worse. The fact that there are people being paid to come up with these surveys, the fact that physician reimbursement may depend on the results, or the fact the physicians willingly put up with this. I know of no other trade or profession that would allow themselves to be abused like this.

        • James O’Brien, M.D.

          What would the American Bar Association do?

          Sue and file a request for a cease and desist order.

          Say what you want about lawyers, at least they are vertebrates.

      • DeceasedMD1

        Wes, thank you for showing this questionnaire online. Forgive my ignorance, but how is this data used and how does the board gain financially from it?

        • Wes Fisher

          My apologies for not getting back to you sooner. I also apologize for the following technicalities, but it addresses your question via the Affordable Care Act:

          The Affordable Care Act specifically placed these surveys in the law as part of what qualifies as a “qualified Maintenance of Certification program.” It is to be administered by a “specialty body” of ABMS (we now assume this body to be, in fact, the ABIM) (Here’s a link to the pdf of the law: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
          (see pgs 365-367 and 962-963) This
          assessment may then use a “composite of the qualified Maintenance of Certification practice assessment furnished pursuant to the physician schedule payment modifier, as described in section 1848(p)(2) of the Social Security Act (42 U.S.C. 1395w-4(p)(2).” In other words, survey results will be used to modify physician payments from CMS under their PQRS “incentive” program. In 2015, this incentive will amounts to 0.5% of revenues. If one considers $77 billion in physician payments were made to physiciansby CMS in 2012, this 0.5% represents a not-too-paltry $385 million dollars. If we also consider 22% of physicians failed to recertify in the latest testing cycle, this represents a considerable
          potential cost savings to CMS. And what does CMS pay ABIM for it’s “quality” data? A portion of $5 million in 2014 and $15 million in the first 6 months of 2015 in a contract with a “consensus-based entity regarding performance measurement” ( http://www.law.cornell.edu/uscode/text/42/1395aaa) – not a bad” fee” relative to the cost savings produced for the
          government thanks to this bogus measure.
          This is regulatory capture, plain and simple, all for the end-game of covert rationing of government payments to those who do the work.

  • maggiebea

    I’m just a patient, but this survey doesn’t begin to answer the questions I’d want to be asked about my doctor — at least, if what the survey seeks to establish is the quality of medicine being practiced. Did I overlook questions about complications? about side effects of medication prescribed by this doc? about whether the doc listened to my concerns about side effects of a current med? whether the doc was available to talk about my advance directive or write a POLST with me? Most of these questions seem to assess the ‘customer service’ portion of our interaction. Not that customer service is trivial. But deciding whether the doc should stay certified based on this questionnaire is like asking whether my (high-speed and trouble-free) internet service provider is keeping my computer connected to the internet by assessing their (abysmal and infuriating) customer service phone line.

  • James O’Brien, M.D.

    In addition to the obvious silliness of this enterprise, what controls are in place would stop someone from cheating if he wanted to? Given that they find it necessary to fingerprint on recerts and the like, this seems pretty lax for the totalitarians who run these scams.

    The whole thing is another beta-test designed to make productive people’s lives as miserable as the people who wrote it.

    All the talk about physicians rising up….if you submit to this nonsense, you have no right to complain.

  • ninguem

    The guards have an Informed Consent form for tasering.

  • SteveCaley

    Logically, the question arises then – does a complaint about intrusive scrutiny suggest the concealment of wrongful activity? Would the prisons be filled with Mengelian physicians, but for the patient surveys of inmates? Should every aspect and angle of authority be permitted license to scrutinize, each in their own way? What if we hit a point where we are so busy divulging what we do, that there is no time to actually do anything?

    We should look very hard at this question, because it impugns privacy.

    If this mindset were in place in 1965, Griswold v. Connecticut might have produced a ruling continuing the state’s obligation to obtain a physician’s prescription for condom uses. If you won’t get a prescription for condoms, then, are you trying to conceal your participation in criminal sexual conduct? Then what are you trying to conceal, citizen?

  • James O’Brien, M.D.

    KOLs often secretly or sometimes blatantly despise private practitioners, yet the rank and file continue to elect them to head medical organizations and willingly submit to their thug extortion demands with MOC.

    When it comes to recert, their ethics seem to be guided by this principle:

    http://brooklynsteez.com/products/square/95038.png

    Nice practice, would be a shame if anything happened to it.

    Many of these thought leaders don’t see patients, and are highly overpaid to the tune of 700k for minimal amounts of work.

    http://www.aapsonline.org/index.php/article/aaps_takes_moc_to_court/

    Meanwhile, they enjoy their prestige with little accountability and despite their condemnation of greed of those in private practice, reap windfalls of obvious conflict of interest pharma honoraria.

  • Julia

    As a researcher, I’m curious as to what reliability and validity testing has been conducted on this instrument. Self-report data are always questionable. I also have concerns about informed consent, both for the doctor and the patient. The doctor is being coerced by fear of losing livelihood to participate in data collection on which all potential future use is unspecified. The patient has no clue what this is all about. It appears that neither is giving informed consent. What is the potential for doctors’ to prescribe unneeded antibiotics or pain meds or order unnecessary tests to prevent a negative report? I certainly wouldn’t advise bringing up smoking cessation or diet and exercise to a patient right before handing over that questionnaire. A number of ethical concerns are raised with this MOC activity.

    As a patient, I perceive very negative changes in my doctors’ offices over the past year or so that are clearly related to Meaningful Use. It’s the worse time to add some subjective self-report satisfaction survey. Despite having good medical insurance, I fear decreased access to health care as a result of the burdens placed on doctors that are decreasing the quality of care.

    As a doctor’s spouse, I’m relieved that this doctor recently took a non-clinical position and we are reclaiming quality of life by stepping out of the path of this imminent train wreck. I know of other good and caring doctors who have left or are planning or contemplating leaving clinical medicine. I only ask who is profiting from all of these burdens, because it is not the patients or the doctors?