The American Board of Internal Medicine's proposed sanctioning of 139 physicians by the ABIM for passing along and receiving exam questions from a test preparation company is getting messier.
Here's why. A lengthy appeals process is underway, with potentially 80 lawyers involved, which always means complexities and various paths toward getting to the truth. And questions are growing, at least in my mind, about whom exactly the ABIM is targeting. One of those physicians cited for sanctioning includes someone who had taken the test at least two decades ago, sources tell me. ABIM proposed sanctioning this person, related to handling of the questions, and the potential is that the physician could lose his or her certificate.
Excuse me? 20 years?
No joke. Why the ABIM is involving this doctor is beyond me. What's the point? Is there a statute of limitations on this?
The individual has not been identified, and attorneys decline to discuss the matter.
The imbroglio over the testing began when the ABIM cited the 139 physicians in June for improper conduct over the testing. The board said it stripped scores of physicians of their board certifications for periods ranging from one to five years.
The major target of the investigation was Arora Board Review, a New Jersey test-preparation course that apparently for years shared information garnered from physicians who took the ABIM test with other would be test takers, according to ABIM. The principal of Arora Board Review has surrendered his certificate to perform the tests. ABIM also has filed court action against Arora personnel for improperly disseminating copyrighted test questions.
The ABIM has sent what some have dubbed "shame on you" letters to about 2,700 physicians who took the test. These doctors were not accused of wrongdoing, but the board believes should have known what was going on and possibly revealed the conduct to the board.
For those 139 physicians whose certificate faces possible suspension, the appeals process is beginning, and already seems drenched in bureaucracy and potential conflict.
As I've been told, there are several levels of appeals that can drag on for months until a final determination is made. The appeals reviewers include representatives of ABIM staff, which may be seen as a conflict of interest. An independent panel appointed by the ABIM will consider the final appeal.
In its inquiry, the ABIM has recovered 36 boxes of paper evidence, six computer hard drives and audio and video recordings from Arora that were used in the investigation of the physicians, according to the Wall Street Journal.
Indeed, although Arora Board Review was the primary target of the investigation, that certainly doesn't excuse doctors who may have inappropriately given answers or taken answers from others. I wrote about this on June 17, quoting Christine K. Cassel, MD, ABIM's President and CEO. She said each question crafted for the ABIM certification exam is "like a precious jewel."
"A couple of thousand people attended (the exam sessions) and not everyone stole questions, but no one alerted us," Cassel said. "If people see unethical behavior they should let us know."
Robert M. Wachter, MD, a member of the executive committee of the ABIM and professor and associate chairman of the Department of Medicine at the University of California, San Francisco, writes in a blog "Dr. Arora ran an ABIM board review course with a difference."
"Attendees of the Arora Board Review were allegedly shown actual questions form past exams, fed to Dr. A from prior test takers—who shared dozens, and in some cases, hundreds of questions," Wachter wrote. He noted that the board is suing Arora and a "handful of the most egregious offenders for significant damages."
"When you took your boards, you signed an attestation or clicked a little box pledging that you wouldn't share the questions with anyone else," he writes. "It's a pledge worth honoring." Wachter could not be reached for comment, his secretary said.
Wachter is correct in what he is saying, to a degree. But it may be worthwhile for the ABIM to examine how it conducts its own investigations.
For instance, the board said it is concerned about the alleged copying or near copying of questions that were carried out over years. But my question is: why weren't there lots of new questions put forth every year? Why would a question that goes back 20 years be an issue now? Officials of ABIM have said that many months' work was put into determining the questions.
And there's another thing: why did it take so long, if word of mouth was so prevalent among the testing service, for the ABIM to figure out that people were getting answers or reviewing questions that had been used before. Were they so isolated that the ABIM couldn't find out about it—if it was going on for 20 years?
Some respondents to Wachter's blog cover the realm of reaction to what has been unfolding in the tests. One writer was very critical of the test takers: "I can't believe people have stooped so low and have so little self esteem that they are not willing to do what it takes to pass the boards."
Another agrees with the "pledge of honesty" that is signed before taking the exam, but notes, "I wonder how just attending the course makes you unprofessional and unethical when you have not taken the exam and you don't know the content."
All those questions may be answered over time.
There is some talk that the penalties may be too harsh, and that possibly the ABIM should consider education programs and other procedures for physicians who may be sanctioned, instead of certificate removals. The ABIM has questions for itself it should have answered as well.
Last month, the names of "private practices" reporting breaches of unsecured protected health information affecting more than 500 people were revealed when the Office for Civil Rights, (OCR) the enforcer of the HIPAA privacy and security rules, lifted the veil of anonymity on the entities.
Judging from my calls to some of these physician offices who reported breaches—and their failure to return my calls, or simply responding with terse "no comment"—many would rather remain anonymous.
But for physicians who were involved in breaches, there are lessons learned, especially for small practices. Sometimes we just assume in this highly connected digital world, that every physician has ramped up to protect his practice against illegal data theft. That's definitely not the case.
One small practice, Daniel J. Sigman, MD, PC, based in Stoughton, Mass, was hit with a breach on Dec 1, 2009, affecting 2,860 patients, according to the OCR. The OCR tally noted: theft, portable devices, and medical records.
A key problem was the manner in which the data was kept in the plastic surgeon's office. Without giving me too many specifics, Kathleen Minnock, office manager, says the data was kept in a bag —similar to a purse —and taken offsite every night.
"We have a small server like many small doctor's offices," said Minnock, office manager, noting that the way the office handled the data seemed inexpensive and convenient.
After the practice learned the data was missing, the nightmare began, she says. The first worry was whether patient data was stolen, or compromised any other way. Thankfully, that didn't occur, Minnock says, without providing details. She says patient data doesn't appear to be compromised. Federal officials, however, demanded that each patient be notified and alerted to what had happened, all 2,860 of them. And over time, Minnock says, the practice has learned the lesson of keeping good records.
OCR reports that at least 11 "private practices" reported breaches of 500 or more over the past year, involving potentially thousands of patients and files.
Several of the breaches involved different practices in related Torrance, CA offices. The Los Angeles Times reported that the medical records of more than 18,000 patients of at least five Torrance doctors were "potentially accessed by cyber-thieves on a single day." I called the practices; either they would not return my call or declined to speak about it.
However, a spokeswoman for another practice ensnared in a breach told me: "It was really horrible. The (doctor) found out about the breaches the same day it happened. He's a victim, yet he's responsible for taking care of it. It all goes back to him." She wouldn't elaborate and he didn't want to discuss it.
Minnock, the office manager at the Massachusetts physician's office, says her office has taken major steps toward improving the manner in which records are kept. "The lesson is, don't take the tapes home, don't take the laptop home. You really need appropriate safeguards," Minnock says. Not only are the records now encrypted, "now they are double locked like the banks do."
But it doesn't have to be a small physician's office to find out the hard way about losing data. "Over at South Shore Hospital, they are big and they had a breach," she points out. South Shore Hospital, in South Weymouth, MA, recently disclosed it had a major breach.
In a statement last month, the hospital reported that back-up computer files containing personal, health and financial information affecting potentially 800,000 people may have been lost by a professional management company, according to a statement from the hospital. The missing files included information on patients, employees, physicians, volunteers, donors, vendors and other business partners dating from Jan. 1, 1996, to Jan. 6, 2010.
The hospital said it sought to destroy the files because they were in a format it no longer uses. Apparently, however, a freight carrier lost a shipment of files scheduled for destruction.
Hospital officials say they have no evidence that information on the backup computer files had been accessed by anyone. An independent security consulting firm told the hospital that specialized software, hardware and technological knowledge and skill would be required to access and decipher the files. Still, the incident is under investigation by state authorities.
The hospital will send letters to individuals affected once it verifies whose information may have been included in the missing back-up files. Once the investigation is completed, the hospital said it will determine whether to provide free credit and identity theft monitoring to any of those affected.
South Shore is only a reminder to Minnock that security can't be taken for granted, as well as the swirling demands of HIPAA compliance.
To help physicians, David Ginsburg, president of PrivaPlan Associates Inc., a consultant specializing in HIPAA, prepared a white paper for the California Medical Association on "Practical Steps Practices Can Take To Ensure HIPPA Compliance. Ginsburg writes that "most medical practices feel they have done all they need to satisfy HIPAA requirements" and are "reluctant to dedicate precious resources to additional compliance efforts."
He urges physicians to "routinely review system activity and conduct technical audits to monitor suspicious activity. Your practice management system should have auditing capabilities to track employee activity and patient accounts."
"A number of gaps can expose medical practices to patient identity theft and violation of state laws," he writes. "It is more critical than ever that physicians review their current policies and procedures" to determine if upgrades are necessary. The best defense, Ginsburg advises, is "not to have a privacy or security violation occur."
In March, I talked with Robert Moffit, PhD, a senior fellow for domestic and economic policy at the Heritage Foundation, who insisted one of the potential losers in healthcare reform was going to be the powerful American Medical Association.
Moffit says the AMA was not a force in the healthcare debate. He says the AMA's arguments languished in Congress as it tried to overturn the sustainable growth rate (SGR) formula that governed physician Medicare payments, yet limply supported the Obama healthcare reform.
Indeed, as Congress dragged out the "doc fix" debacle, the AMA would issue statements saying that patients were the big losers and Congress needed to act. The AMA's press statements often sounded the same, with the difference being some quotes. I thought the press releases were quite tame. Moffit thought they were weak. Moffit indicated that the AMA would pay a price for what he saw as waffling in the healthcare debate.
After the votes in Congress, I kept thinking: where's the fallout for the AMA? Was Moffit wrong? Was this just another conservative taunt from the Heritage Foundation?
But in the aftermath of healthcare reform, there is no doubt some physicians are furious with the AMA and even some of the organization's strongest supporters say the organization must rethink its approaches as it moves ahead. In August, the Florida Medical Association is scheduled to consider a resolution to break away from the AMA. Moffit thinks it's just the beginning of political trauma for the AMA. We'll see.
The Florida Medical Association resolution says that the AMA "failed to achieve one single concession" in the healthcare reform legislation, according to The Hill, the Washington newspaper. The resolution says the AMA is "failing to lead and represent America's physicians."
The Hill didn't reach the sponsor of the resolution, Douglas M. Stevens, MD, a Fort Meyers, FLA, plastic surgeon, but I did. He confirmed the resolution, saying "in Florida physicians have seen what government sponsored healthcare is and think it's a disaster.
The AMA consistently failed us on the signature U.S. healthcare policy—and failed us miserably," He added, "I'm not clear whom the AMA is representing anymore."
The AMA has not commented on the Florida Medical Association resolution.
"This is definitely heavyweight stuff," Moffit says of the Florida resolution. "Doctors want to change the whole way in which they deal with Washington—different from this whole business of going along, and getting along. That's what the AMA does. We are at a watershed."
"Florida has a huge group of doctors who serve Medicaid patients, and also serve Medicare patients," Moffit adds. "Physicians are going to be on the receiving end of basically a price controlled payment system, which limits their outcome and also limits their options.
The Florida vote may be a big deal, or it simply could be one physician's resolution that will be shouted down in a chorus of "nays." That's what basically happened in May in Texas, where a resolution to have the Texas Medical Association be removed from the AMA was discussed, Susan Rudd Bailey, MD, president of the Texas Medical Association, told me. The group, which represents 45,000 members, quickly dispatched the idea, she says.
"I think we and the AMA have not really differed widely in our opinions about what needs to be done in health system reform," Bailey says. "The major differences have been in strategies and tactics that were used when the bill was debated in Congress."
"The biggest question is whether the AMA should have fallen on its sword over SGR. Should they have withdrawn (their support) for the rest of the bill because the SGR fix wasn't in it? They decided not to. A lot of physicians are frustrated and angry. But the AMA is a very easy scapegoat."
"There needs to be a national organization that speaks for all physicians regardless of specialties, regardless of where they are in their careers. If the AMA fails or ceases to exist, we have to create another one like it," Bailey says.
In addition, the reach of the AMA should not be misjudged, she says. "The AMA does so much more than advocacy," she says. "If we lose the AMA, we lose all those other things as well." The AMA has about 240,000 members, representing about 20% of U.S. physicians. Critics believe it will see a cascade of lost membership in the wake of healthcare reform.
Bailey says she believes the AMA is strong, but may need to change. It may have to become a "different type of organization," she says, such as an "organization "become an organization (that represents) various organizations of physicians."
Still, the AMA has been important as a voice for physicians, Bailey says. "I think change is much better from the inside."
We're not talking Bush-Gore in Florida, but there are many political issues involved, conservatives vs. liberals in the undertow of healthcare reform, as Bailey notes.
Moffit agrees that the political undertones are strong in whatever region of the country addresses the healthcare issues and feelings about the AMA reflect that. Whatever happens with the AMA, "it can't be a 'get along and be along' organization, Moffit says. "They are only going to splinter themselves. They can't be like Caspar Milquetoast."
The Florida Medical Association's delegates are expected to vote on Stevens' resolution at their meeting Aug. 13-15 in Orlando.
Stevens says he has no idea how the vote will go on his resolution to disengage from the AMA. Whatever happens, "the discussion is what's really important," he says.
The physician is about to close the door, and the patient blurts out, "I have these chest pains."
Shouldn't that statement have been mentioned at the beginning of the visit?
Wendy Levinson, MD, chair of the department of medicine at the University of Toronto, and her colleagues called it the "oh, by the way?" moment in a paper they wrote in the 1990s. In the piece, they describe how sometimes things go wrong in whatever words are exchanged between patient and physician, which leads to their failure to really discuss what matters until the end of the visit.
Recently, Levinson brought up her article, written years ago, in a conversation with me about physician and patient communication, which is a continuing, if sometimes stumbling, journey of discovery for both sides. She mentioned the article because she's broadening her arguments about the need for improved communication in patient-centered homes. As healthcare reform gets going, communication is more important than ever—with the need for broader federal reimbursement, and C-suite involvement, she says.
Levinson's bottom line: Doctors should be paid more for their conversations with patients—and the result may be improved patient care.
"Complicated conversations such as breaking bad news or disclosing medical errors could be reimbursed as complex procedures," Levinson writes in "Developing Physician Communication Skills for Patient-Centered Care" in the July issue of Health Affairs, with co-authors Cara S. Lesser, MA, director of foundation programs for the ABIM Foundation in Philadelphia, PA. and Ronald M. Epstein, MD.
Under current procedures, the Centers for Medicare & Medicaid Services (CMS) pay for more than 7,000 types of physician services, identified in codes developed by the American Medical Association. But the term "complicated conversations" doesn't apparently come up.
The codes could include "face-to-face" encounters between physicians and their patients, but that's when the physician usually takes the patient's medical history, performs appropriate examinations and makes decisions about course of treatment or management of a patient's health, says Ellen B. Griffith, spokeswoman for CMS. When appropriate, the codes also can be used to pay for the time a physician spends with a patient or caregivers discussing the patient's condition and other concerns.
Recognizing that physicians may not be aware of these options, Griffith says, CMS published a 2009 Caregiver Initiative guidance that says physicians seeking reimbursement may spend as much as 25 minutes counseling a patient and family out of a 40-minute visit.
But Levinson says more communication time should be considered by CMS for payments, particularly in relation to certain illnesses. In addition, the federal government should consider reimbursement for medical students in the last year of school and residency training for communication training, when communication skills are not developed as they should, she insists. Continuing training for physicians also should include communication programs that should be reimbursed, she says.
"It is in the third and fourth years of medical school, during clinical rotations, when students have the most patient contact and face their greatest cognitive and emotional challenges," she writes. "Unfortunately, the teaching of communication skills often receives little attention when compared to the teaching of diagnostic skills and patient management."
"Medicare and other payers have the ability to further increase the demand for patient-centered communication through reimbursement strategies," she writes. "By being procedure-oriented, they aren't well reimbursed.
Reimbursement strategies can be devised to support patient-centered care through the use of patient survey scores, payment codes for patient education and counseling, according to Levinson.
When pressed (by me), Levinson acknowledges CMS already pays a lot for doctors." But, she adds, "If it [were] tied into the whole patient-centered medical home, it can be a vehicle, a new mechanism for paying physicians. It could be linked to the patient centered care, for complicated conditions."
The C-suite also can play a role in improving patient and physician communication, she says.
"Leaders and administrators can model desired communication skills on their interactions with physicians and staff, setting high expectations for effective communication in all interactions," she writes. "Making the importance of communication between physicians and patients and among health professionals part of a medical group's culture can have a profound impact on the degree to which patient-centered care is the norm."
"Increasingly, organizations are looking at the patient experience," she tells me. "If you permeate the culture with views of the patient, this can be transformational. It can change the culture. It can take the c-suite to do that."
The importance cannot be overstated in patient-centered care, and also reveals a gap in communication between physicians and patients that needs to be closed, Levinson says. "When I tell a physician at a cocktail party that I work in healthcare communications, they go "oh" with some disinterest, she says. When she tells patients, they say, "Let me tell you a story," stressing what they consider to be the importance of what they told the physician—and how the physician reacted.
The changes needed to improve communication between patient and physician won't come immediately, and, whether more federal funds are injected or not, won't occur overnight, according to Levinson.
But neither are the possibilities for change "out of reach," she writes. "We have a moral imperative to meet this challenge, because doing so will improve the quality of care."
TV and movies have often focused on physicians, truly part of the country's entertainment landscape. There have been certainly enough fictional "doctor" shows over the past five decades, from Dr. Kildare to House, with barely a glimmer of reality attached. As for reality, Michael Moore's 2007 documentary Sicko, touched on physicians, but mostly as a sideshow to his major viewpoint of the U.S. healthcare industry's flaws compared to the rest of the world.
But the underbelly of a doctor's lot: billing codes, malpractice, their feelings about patients, patients' feelings about them, the frustration of only having 10 minutes to give to a patient — haven't been given truly much focus on TV or movies.
At least that's what Ryan Flesher, MD, was thinking. To give his perspective to a doctor's life, Flesher spent four years directing a documentary, "The Vanishing Oath" produced by Nancy Pando, LICWS and released by CrashCartProductions.
Flesher's story is about himself, and also other physicians caught in the whirlwind of the healthcare system, their day-to-day exhaustion and unhappiness woven in a tightening bureaucratic vice. The film was the result of interviews with hundreds of people, not only doctors themselves, but patients, academics, lawyers, and others. It is often sad, but occasionally inspiring.
Flesher, 37, who worked in a Boston hospital emergency department, leaped at the chance to make the film after increasingly becoming unhappy in a system that seemed to unravel, becoming "critically wounded," he said, with doctors bailing out of their chosen profession, because they weren't able to have enough time: for their patients or themselves.
Flesher hated being a physician in a manner that he says the system demands. "It was just pretty frustrating," he says. "Since I was young, I focused on becoming a doctor." Over time, as he grew more unhappy, " I began asking myself, 'what's wrong with me, why am I so unhappy? After four years of filming, it educated me and brought me to a better place. I wasn't alone, there were thousands of people who were also frustrated, their hands were tied by the system, and they were discouraged."
Flesher dubs it the first "physician focused" documentary, and it's good for health leaders to see it from that prism.
On one level, we know the story. Questionable procedures. Too much paperwork. The costs of malpractice suits. Upcoming doctor shortage.
In Flesher and Pando's hands, however, the facts of being a doctor in America today become wrapped not only in numbers, but also in emotion.
It's sad to watch physicians weep with despair over their profession, trying to wring some time for themselves or their families, and frustrated they can't see most patients beyond what their charts tell them, and the few allotted minutes in their schedule. It's exhilarating, however, to watch a few select physicians who say they will never give up on the dream.
And that makes the documentary more riveting because doctors tell intimate details of their profession as they see it. Some of those emotions might not make it to the C-suite on a day-to-day basis, while physicians make the rounds. It's emotions that health leaders should see.
By injecting himself, Flesher does a sort of Michael Moore routine, but he's no wise guy. Just an exhausted emergency department doc. When they began filming, Pando says Flesher's "eyes were hollow."
One day, Flesher talks to the camera, as he sits in his green scrubs in the hospital where he was working.
"We're just jammed, ambulances everywhere, beds full, I'm carrying 16 or 17 patients of my own, pretty sick," Flesher says in the documentary. "Before I go three steps, I'm confronted with the billing agent for the ER who says we can't get paid because my charts — eight of nine — required review assistance components. Two, I'm confronted by the service rep for the hospital (who says) my patient satisfactory scores are only 93% - we've got to be above 96."
"The CEO says we are getting backed up (in the emergency room), and we need to get patients through the ER quicker," he adds. "The Joint Commission rep says she caught me drinking three feet too close to the patient care area and she's going to cite me for—whatever. I didn't even see a patient yet and my mind is already clouded."
As he began working on the film, Flesher found out many others were disheartened, and he felt the system failed them.
"The obstruction of physicians and its direct effects on healthcare are far more profound and potentially devastating than I'd imagined," he says.
In his journey to find himself, Flesher seeks out an older and accomplished physician, Peter Rosen, MD, who has received numerous awards in the field of emergency medicine. He expected Rosen to be stodgy. He found otherwise. He found a wise man.
"I think you can work to prevent (burnout)," Rosen says. "The important thing is to revive your ideals — why did you want to be a doctor? Because it still exists, no matter how many hidden agendas you have to meet at work, no matter how many stupid pieces of paper you have to fill out."
"Despite that, I can still have fun taking stitches out of that 5-year-old kid and joking with him for a minute and a half."
Rosen's inspirational comments run through Flesher, but they last only so long.
Now out of residency for 8 years, Flesher left the hospital and became a traveling, part-time physician, "to get more time and flexible schedule" to carry out interviews and make the film. He is working mostly in Pennsylvania and West Virginia.
Flesher's wife, Kathrin Allen, MD, is an anesthiologist. Does she agree with the film? "She does for the most part," Flesher says. But she's only been in practice for a year and a half, and, Flesher adds, "isn't so jaded yet."
After just moving to San Diego, I went to lunch in a crowded La Jolla restaurant with a friend, and he quickly exclaimed, "All those Zonies."
Zonies?
Arizona residents who escape the heat and go to San Diego for its nice balmy weather; that's why the restaurant was so packed, he said.
Our little exchange about Arizonans was carried out in good humor. It was the late 1980s and Arizona's population was beginning to escalate. Yet there was little doubt once the Zonies ended their vacations in California, that they would leave, and our restaurants would be less crowded, as well as the beaches and everything else.
The population growth continues in Arizona, especially among older baby boomers. In the meantime, there are increasing questions about who is going to care for their patient population, according to a 2005 study on physician workforce by the Arizona State University Center for Health Information recently released.
From 1994 to 2004, the physician workforce in Arizona increased from 8,026 to 12,024, at a rate higher than the overall population increase in the state at that time. But the ratio of physicians to population in Arizona was 207 per 100,000 in 2004 — considerably below the national average, which was 283 per 100,000.
And the estimated 2010 national ratio is about 299 physicians per 100,000, and 213 per 100,000 for Arizona, according to The Arizona Republic. That gap is still significant, William G. Johnson, PhD, director of the center and professor of ASU's biomedical information and co-author of the report, said.
The Republic's story about the study, has gathered a lot of attention. But the state isn't alone in trying to keep physicians home, that's for sure. I checked the U.S. Census Bureau, http://www.census.gov/compendia/statab/which noted the ratio of physicians to populace as of 2007. States having a lower number of physicians per 100,000 than Arizona included:
Idaho, 169
Oklahoma, 173
Mississippi, 178
Iowa, 189
Arkansas, 203
Utah, 208
Texas, 214
One of the biggest issues for some states is that they are not cultivating their own physicians. That's specifically Arizona's problem, according to the study.
Only 10% of the physicians practicing in Arizona attended medical school in Arizona and only one-third of Arizona physicians completed residency training in the state.
"With the decreasing popularity of family medicine and decreased number of family medicine residency positions in the state, it is unlikely that medical education in Arizona can expand to a level where even one-half of the practicing physicians will have attended medical school in Arizona," the study says. "Therefore, Arizona will continue to rely on the in-migration of physicians to maintain its physician workforce."
J. Fred Ralston, Jr., MD, FACP, president of the American College of Physicians, said states are encouraged to do what they can to maintain physicians. "Funding for training programs or scholarships for people to practice in some areas has shown success in some places," Ralston explained. "But realistically, with most of the states facing budget shortfalls, I'm not sure they have the financial resources to commit to that. Now you have a perfect storm of having shortages in some specialty areas, exactly the time the baby boomers are requiring more doctors."
Nationwide, physicians will "presumably increase competition among the states for the pool of physicians," according to the Arizona report. "Arizona faces a more difficult problem than other states because its population is increasing."
In Idaho, where the physician-population ratio is worse than Arizona, 169 per 100,000, the lack of physicians is troubling, according to Susie Pouliot, CEO of the Idaho Medical Association, which represents 2,000 physicians, about 70% of the state's total.
"Concern is not too strong a word," said Pouliot. "Among our priorities is ensuring a physician work force now, and in the future." The University of Idaho is a member of WWAMI, the University of Washington School of Medicine regional medical education program, and Idaho students have training outside the state. As a result, the IMA is working to initiate a variety of medical educational support programs, expand resident training, and offer increased support for existing workforce to encourage future Idaho physicians to stay home, Pouliot said.
Thomas Striegel, an emergency department resident at the Maricopa Medical Center, told the Republic he had mixed feelings leaving Arizona to continue his practice at his family home in Iowa.
But Iowa has 189 nurses and doctors per 100,000 population, the census figures show, also less than Arizona. Iowa may need him more than Arizona.
Barbra Rabson, executive director of the Massachusetts Health Quality Partners, spent a few months with her staff evaluating patients' responses to questions about how patients reacted to their primary care physicians in the wake of the state's landmark healthcare reform law. After the MHQP questioned 80,000 people, Rabson says she had her fingers crossed.
Contrary to her expectations, doctors and patients seem to be talking more than ever, and physicians seem to be trying more than ever to learn about their patients, she says, referring to the findings of the MHQP's latest statewide survey.
"We had our fingers crossed on this one," she says. "I was really surprised. One of the big surprises is that patients report as good experience as they do, given all that is going on in the marketplace, after we implemented healthcare reform, and insured over 400,000 new people in Massachusetts."
The Massachusetts healthcare reform law was enacted in 2006, and one of its provisions is a requirement that every resident obtain a minimum level of health insurance. The federal government's healthcare reform includes a provision that would add 32 million people to the insurance roles in the next few years.
The MHQP survey -- Quality Insights: Patient Experiences in Primary Care -- showed some improvements in how commercially insured patients rated their experience with primary care physicians, compared to two years ago. MHQP is a non-independent coalition of healthcare leaders who say they use quality measures to improve health services in Massachusetts.
MHQP polled 56,000 adult patients and 22,000 parents of pediatric patients about their experiences with primary care physicians. Some 500 adult and pediatric primary care practices statewide participated.
The MHQP report is based on what patients say about their actual experiences with their primary care physicians, including: how well the doctors listen to and communicate with their patients; their knowledge about their patients' medical history, values and beliefs, how they coordinate their patients' care with specialists and provide preventive care and advice, and whether patients would recommend their personal doctors to family and friends.
The report also assesses how well physician offices handle patients' access, service and care needs, such as whether they feel they get timely appointments, care and information, and whether they feel they can see their own doctors when they need an appointment, and whether they feel they get adequate level of service from office staff.
In one of the most important response categories, "Knowledge of Patient," there was increased patient satisfaction reported in the survey, Rabson said. Patients reported:
70% of physicians "always knew important information" about patients in 2009 compared to 67% in 2007
70% of pediatricians "always knew important information" about patients, compared to 73%
In a sampling of questions in 2009, patients were asked about interactions with their adult care physicians' the previous 12 months:
83% said their physicians were easy to understand
82% said their physician listened carefully
59% said their physicians were informed and up-to-date
38% of patients said they saw their doctor within 15 minutes of an appointment
In a sampling of 2009 questions of families of pediatric patients:
86% said physicians listened carefully
86% said physicians gave clear instructions
64% said physicians seemed informed and up-to-date about their child
"Doctor-patient relationships improved over time," Rabson says of the survey findings. "There were so many people who feared that with healthcare reform in the state there would be an impact on patients' attitudes about physicians -- that it was going to get worse in Massachusetts. It didn't happen."
Despite' Rabson's upbeat reaction to the survey results following healthcare reform in Massachusetts, there were some "negatives" in the poll findings. In the latest survey, 40% of adult patients and 35% of parents of pediatric patients reported that their physician did not always seem well informed about the care they received from specialists to whom they had been referred. In addition, the survey found that about 30% of adults and pediatric patients did not always receive follow-up reports on test results from the doctor's office visit, unchanged from 2007.
"Everybody is talking about the importance of patient care," she adds. "You have to work really hard for it. We believe that patients should expect certain things when they see a doctor, and while we acknowledge that most of our primary work is in a fragmented system, we still can't blame the system."
"MHQP's survey asks about aspects of the primary care experience that are fundamental to high quality care," Rabson says. "The survey allows us to understand how patients are experiencing care during this time of great change in our healthcare system."
Framingham Pediatrics in Massachusetts is one practice where there have been high expectations of families of patients, and they often have been met, according to the MHQP survey. Nancy Rosselot, MD, says the practice uses the MHQP data to evaluate their performance and progress. Each of the physician offices whose patients participated in the MHQP survey is provided with detailed information on its own scores, so they can compare themselves with their peers and use the data to focus on quality improvement efforts, the MHQP said.
"We've been pleased that patients feel good about their access to care," Rosselot says, referring to specific data findings related to Framingham Pediatrics. "There are small things that could be identified as needs for improvement. We as a team are working how we can improve coordination of care. We need to go that extra step. We're tracking patient calls and making appointments in a timely fashion."
After participating in the MHQP survey, Framingham Pediatrics established a new position -- medical home coordinator -- to improve coordination of care, Rosselot says. The new position has been especially important in tracking test results and working to ensure a coordinated relationship with patient specialists, she adds.
The improvements that Framingham Pediatrics is making reflect the "exhaustive work by some physicians to improve communication with patients," Rabson says.
As Massachusetts goes forward with its healthcare reform, there's more work to be done, and each step it takes is a lesson for the nation too, Rabson adds.
At first glance, you don't quite believe it, when you read the findings of a recent Annals of Internal Medicine study that examined U.S. medical schools for their collective social consciousness: namely, that some of the nation's most prestigious medical schools—Johns Hopkins University, Stanford, Duke, Texas A&M, and Columbia, to name a few—are ranked near the bottom in terms of graduating physicians who continue to work in primary care, or work in underserved areas, or are underrepresented minorities.
The study, "The Social Mission of Medication Education: Ranking the Schools," bills itself as the first to evaluate U.S. medical schools, not on their academic standing, but in their ability to carry out a "social mission."
It's a study touted by its authors as groundbreaking. It's a study denounced by its critics as nothing more than a "limited picture" of medical schools.
Candice Chen, MD, co-author of The George Washington University study, contends it is important because it reveals outcomes of a medical education following graduation, in the context of social service, which she says is hardly measured in academic circles. With a primary care shortage enveloping the country, as well as greater disparities in patient populations, focusing on these issues is becoming more relevant, Chen says.
"There's such a difference between the top 20 and the bottom 20, for instance, in how many primary care physicians they graduate," Chen says. "We're not trying to berate any of the medical schools, we're just saying that in terms of social services, some schools are more successful than others, and others should learn from them."
"Primary care physician output, practice in underserved areas, and a diverse physician workforce have persistently challenged the U.S. health system and medical education," the study states. "This analysis reveals substantial variation in the success of U.S. medical schools in addressing these issues."
It found:
Public medical schools graduated higher proportions of primary care physicians than their private school counterparts.
Schools with substantial National Institutes of Health research funding generally produced fewer primary care physicians, and those in underserved areas.
Schools in the Northeast generally performed poorly in the social mission category.
Historically black schools had the highest social mission.
The researchers reviewed records of 60,043 physicians who graduated from 1999 to 2001 and completed all types of residency. The study included an analysis of data from the American Medical Association, and data on race and ethnicity in medical schools from the Association of Medical Colleges, and the Association of American Colleges of Osteopathic Medicine.
The researchers then constructed a social mission score to summarize overall performance of the country's 141 medical schools in producing graduates who practice primary care, worked in areas with a federally designated shortage of health professionals and belonged to underrepresented minority groups. In some cases, some schools are better in certain categories, but still lagged behind in overall social mission scores because of their performance in other areas.
Not everyone is happy with the study, saying that it fails to reveal the full scope of a medical education in the U.S. Others believe the information is outdated.
The American Association of Medical Colleges issued a statement denouncing the study, noting: "Like other attempts at ranking medical schools, this study falls short. By defining 'societal mission' and 'primary care' so narrowly, it provides a very limited picture of medical education's many contributions to society in the U.S. and around the world. And that serves no one well."
The study "presents a limited picture of how medical schools serve society's needs through their integrated missions of education, research, and patient care," the AAMC adds. "While producing primary care physicians, ensuring more diversity in the physician workforce, and encouraging more doctors to practice in underserved areas are important parts of that mission, they are not the only components."
But seriously, what's wrong with throwing more issues into the debate about medical schools, and broadening the scope of reference, applying some new models to the real, changing country?
"Obviously, medical schools do a lot of good things, they put out a lot of high-tech research, a lot of clinical service," Chen says in response to critics of the study.
"But in the U.S. there's obviously a more apparent need for primary care physicians, and we have a growing minority population and acute access issues for a growing population. Among those with the "highest social mission scores" named in the study are Morehouse College, Meharry Medical College, Howard University, Wright State University Boonshoft School of Medicine, and the University of Kansas.
"The three historically black colleges and universities with medical schools—Morehouse College, Meharry Medical College and Howard University—score at the top of the social mission rankings," the study says. "These results are not unexpected as 70% to 85% of each of these schools' graduating classes were underrepresented minorities compared with only 13.5% in all medical schools during the same period."
Having underrepresented minorities "significantly increases the schools' social mission scores," the study notes. "However, all of these schools also score in the top half of the primary care and underserved output measures."
Among those with the lowest scores: Vanderbilt University, University of Texas Southwestern Medical Center, the Northwestern University Feinberg School of Medicine, the University of California Irvine, and New York University.
Vanderbilt Hospital, which ranked last, said the study doesn't offer a complete picture or update its goals since 2001. "The findings are outdated and do not capture the vast number of initiatives that Vanderbilt has implemented over the past decade," Bill Hance, assistant vice chancellor for news and communications at the medical center, told The Tennessean.
On the other hand, Wayne Riley, president and CEO of Meharry, which ranked second, told the paper: "This study, in a very elegant way, validates the fact that we are truly a national treasure."
Chen likes the idea that the study is spurring debate. "We are putting so much prestige on some schools, but others that are truly producing physicians performing social services aren't getting the credit they deserve," she says.
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Each question crafted for the American Board of Internal Medicine board certification exam "is like a precious jewel," says Christine K. Cassel, MD, ABIM's President and CEO. It sometimes takes two years to form the questions, with the right precision and nuance that elicits medical knowledge sought, she says.
Cassel's not saying it's an easy test, but that if you study, you've got good chance of passing, with data showing that 88% passed the first time in 2009. That's only one of the reasons why she's "sickened and dismayed" that the ABIM has had to suspend or revoke the certifications of at least 139 physicians who "solicited and shared examination questions." The tests occurred over several years, and hundreds of questions were compromised.
What further troubles Cassel is the silence of potential exam takers, among the thousands of physicians who might have known the questions were shared and did nothing about it.
Following a six-month investigation, the ABIM cited the 139 physicians, but many others weren't cited, but may have known what was going on, and kept the information to themselves, Cassel told me. You know, the classic case of car accident scenes, where witnesses don't come forward. But here's the rub: these are physicians who didn't come forward. They were witness to something potentially wrong and did nothing about it.
"A couple of thousand people attended (the exam sessions) and not everyone stole questions, but no one alerted us," Cassel says, expressing clear disappointment in her voice. "If people see unethical behavior they should let us know." Of the people who took the tests "actually see and sign documents that they will respect the intellectual property and agree not to share any of the material of the exam," she says."It's not subtle."
The conduit for the improper action, she and other ABIM officials say, is Arora Board Review, a New Jersey test-preparation course, which apparently received copies of the ABIM test questions for several years from physicians who took the tests. Eventually the company posted test questions on its Web site. .
An " investigation revealed that (Arora) course operators repeatedly told participants that they were receiving actual ABIM questions and requested participants to send questions to the course operators after their exams," according to an ABIM statement. "As a result, any physician who ABIM has reason to believe took the course will receive a letter expressing ABIM's concern about their failure to notify ABIM about the questionable activities."
The 139 people were sanctioned for "unethical and unprofessional behavior," says Loris Slass, spokeswoman for ABIM. The ABIM's action mostly "applies to what (the physicians) did with the information after taking the exam and that undermined the certification process," Slass says.
Slass says the organization sent letters to as many as 2,700 physicians who were Arora customers who apparently did not come forward with any suggestion that actual ABIM test questions were part of the Arora Board Review list of questions. The spokeswoman would not reveal contents of the letters.
The overwhelming number of physicians weren't reprimanded, though, with Cassel believing that a line needed to be drawn to single out the particular egregious offenders, those who potentially shared dozens of questions from previous ABIM tests. There were press reports that some physicians eventually came forward, but Slass said the ABIM began its investigation through internet surveillance and not from information from Arora customers.
There were other ramifications, beyond the physicians. The ABIM, a non-profit independent evaluation organization based in Philadelphia, was forced to have workers spend day and night crafting new tests, spending countless hours and money to undo the damage. The Arora Board Review has suspended operations, and also agreed to pay undetermined damages to the ABIM.
The Arora Board Review's principal, Rajender K. Arora, MD, has surrendered his certification to perform the tests, according to the ABIM. In a court filing, ABIM alleged that Arora and other associates improperly disseminated copyrighted test questions. Physicians paid between $1,000 and $1,495 for the Arora Board Review courses.
The questioning in the ABIM's board certification process evaluates what it terms the "knowledge, skills and clinical judgment" of participating physicians and "assures that those who are certified have demonstrated the requisitive expertise to deliver excellent patient care in internal medicine."
"Every single one of these questions is like a precious jewel," Cassel says. "We get a group of experts from all over the country who come together to write these questions and then edit, and have them have them pre-tested and tested to make sure everything is valid," she says. "It takes two years to make one question that works. It's a huge amount of staff time. Every one of those questions is very valuable, and hundreds of questions were exposed."
A sample question used by ABIM, and provided to HealthLeaders Media, begins:
A 14-year-old boy noted swelling of the right arm and had 15 minutes after shop class . . . "
The Arora question starts:
A photograph of a white 14-year-old boy is shown with swelling of his right forearm that developed after attending a class on wood chopping . . .
Generally, investigators for ABIM found in this question and others that the Arora question "is almost identical to the ABIM question and contains the same unique fact pattern."
Physicians who solicited or shared questions from Arora Board Review could be suspended for at least one year or more, based on the seriousness of the offense.
"Thousands of physicians go through the test every year and almost do it honestly by studying and learning what they need to know," Cassel adds. "It made me feel dismayed and sort of sickened, because it's my profession that I care deeply about and we set a standard for ourselves, what we are doing for patients and the public."
The heartache may not be over, though.
Because of what happened, the ABIM is conducting an investigation of other testing services, Cassel says.
"We have ongoing surveillance," Cassel says. "We have increased this. We do scan all the review courses as well as the blogosphere. We do have ongoing investigations of a couple of additional programs, but nothing to suggest anything like this."
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I remember the night our teen-age son complained about terrible stomach pains and then he said he had trouble breathing. It was on the weekend, the netherworld of medical care. Should we go to the nearby hospital emergency department? Should we wait, or leave a message on the family physician's answering service?
Not much debate. We went to the emergency department.
It's no secret that some people use the emergency room as a quick cure all, when they should be going to see their primary care doctor, me included. Such action balloons medical costs. But when your child feels sick, it's a different story and you don't have that immediate power of hindsight.
But questionable ailments don't stop with children. Sandra Schneider, MD, had a bad stomachache, too, around 2 a.m. on a Thursday night. But she decided to wait it out. She waited to see her primary care physician when the doctor could see her. That was 14 hours after she first felt pain. Looking back, she wonders if she should have just gone to the ER. And that's not only because she's president-elect of the American College of Emergency Physicians.
I talked to her about emergency care in the wake of a Excellus BlueCross BlueShield report that says in Upstate New York, two out of five non-overnight visits to hospital emergency departments are unnecessary. My colleague Cheryl Clark quoted criticism of the report by Gerard Brogan, MD, president of the New York American College of Emergency Physicians, as well as Schneider. They said the report lacked data and was inconclusive and unfair.
The Excellus report, issued May 25, focuses on 640,000 trips to emergency rooms that patients made for such ailments like sore throats, ear aches, upper respiratory infections, and other minor medical problems in 2008, saying that many of these patients could just as easily have gone to a primary care doctor for treatment, at much lower cost.
The report said that one of four ER visits in which the patient was treated and released in the same day turned out to be for a medical issue in which care wasn't needed in a 12-hour period. Some treatments, such as ear infections, should have been treated sooner, but easily could have been done in a primary care setting, the report states.
The report itself displays a big hole, simply by its language. It says the analysis covers the "number of potentially unnecessary hospital room visits" that it says led to overcrowding and wasteful spending.
Potentially? That leaves too much room for, er, potential variables. Schneider agreed that the term was ambiguous. "It says potentially–potentially something your primary care physician could handle? But it could be potentially something your primary care physician couldn't handle, and if you didn't come to the emergency department, you could have lost valuable time," she says. "The report doesn't look at what the patient could have had."
In my conversation with them, officials of American College of Emergency Physicians were quick to summon other studies that they said contradict the Excellus findings, at least on a national level, about the usage of emergency departments. For instance, the The CDC's National Center for Health Statistics noted last month in a report, Emergency Department Visitors and Visits: Who Use Emergency Rooms in 2007, that 10% of emergency department, or ER visits by persons under age 65 were considered non-urgent, far less than the 25% figure in the Upstate New York study.
Schneider says primary care physicians are referring patients to the emergency department, and have been doing so for some time. In 1993 a study performed at Schneider's hospital, Strong Memorial Hospital in Rochester, showed that 88% of patients had a primary care physician and that 50% of them "had called their physician before coming to the emergency department and were told to come to the emergency department," she says. "This was an unpublished study involving 2,000 patients coming into our hospital. . . . We are in the process of repeating that study in our institution. To date, it appears that 80% of the patients have primary care physicians and that about 40% of them have been told to come to the emergency department.
When Schneider suffered the stomach ailment, she was convinced she had gallstones. Her doctor never determined what she had, and eventually she felt better. Ironically, she later treated a woman in the ER who had a similar ailment, and her condition really was gallstones. After the quick diagnosis, the woman eventually was treated, and recovered.
Looking back on her own condition, Schneider said, "Why should I have suffered for 14 hours? When I saw what happened to the woman, I said to myself, 'you fool, you sat at home, feeling nauseated and in horrible pain for 14 hours and you could have had some relief.' That's why in these situations primary care physicians are sending their patients to the emergency department. We can work through it, very quickly. We have the ultra sound, the blood tests, and the medications right there."
Various studies have focused patient usage of emergency departments. An Urban Institute study found that even after Massachusetts adopted universal coverage, visits to the emergency department remained high, with some people just finding it was more convenient. In looking at the uninsured use of emergency departments, the NCHS report said "uninsured persons are not more likely than others to assess the ED (emergency department) for non-urgent visits."
Schneider says she understands the focus of the criticism of emergency care. "We are doctors for the uninsured." But questions about "appropriate treatment" can be spread across the medical spectrum, Schneider says.
"We don't hear about cardiologists, or allergists, or plastic surgeons, or psychiatrists or anyone else, whether they have appropriate treatments. I strongly suspect that not everyone who goes to those places has an appropriate visit," Schneider says. "Emergency departments are the low hanging fruit, the cause célèbre."
As to my son's condition, he spent about 45 minutes in the emergency department where he was watched closely and given fluids. Apparently, earlier in the day he drank much too much soda, and the food he ate didn't agree with him, either. We never really got an explanation for the breathing problems.
When I talked to Schneider about my son's ER visit, she said, "That would have been considered an unnecessary visit. But should you have waited until Monday until you see a doctor? I don't know how you have would slept at night."
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