Why I Am Firing My Family Medicine Board

I am firing my family medicine board, the American Board of Family Medicine, through which I have held certification for a long time.

First of all, some clarification: board certification is not required for state licensing. Once upon a time it was little more than a nice fancy title one could put after their name: “Diplomate, Board of Specialty Medicine.” It was a status symbol at one time, much like being named in “Who’s Who in America.”

Physician licensure is maintained by the State, and has nothing to do with board certification. All physicians must must renew their licenses yearly and attest that we have achieved a required amount of continuing medical education. Board certification is generally more related to what kind of original medical education a physician received: were they taught to research and study on their own, or just spoon-fed facts and taught to regurgitate them and take multiple choice exams? Can a physician think on their feet and outside the box?

The problem with many board certifications is that someone along the way decided they are schemes to remove physicians from their money.

Over the years, medicine boards have moved from a one-time passage of board exams to requiring reexamination every few years, and these exams are very costly. Many boards have implemented “maintenance of certification” programs with annual fees. Board exams have been made increasingly difficult in order to sell expensive Board Exam Review Courses prior to the exams themselves, and revenue from the study guides goes directly to the boards. Legislation has also been passed making it difficult, and potentially illegal, for physicians who have recently passed the exams to pass useful information to other physicians about to take them. And there is no recourse for addressing grievances.

In short, the board certification process has, in my opinion, become completely untenable. At least for the American Board of Family Medicine.

Back when my employer expected board certification, and when the insurance companies they billed required the same, I spent the money and was reimbursed at least a portion of it. But when I walked away from hospital employment and opened my own practice, I began working for patients. This forces me to look at those dollars quite differently. Is it truly a good investment for my patients to spend their money for my board examinations, or the costly yearly maintenance of certification programs? Sure, I get continuing medical education credit, but how much of what I am learning (i.e., to pass a multiple-choice exam) can be put into practice and actually benefit my patients?

As it turns out, I believe my patients—my employers—receive very little tangible result from my effort in maintaining that board certification. I can obtain just as much education and updates on treatment from far less expensive forums.

So, there you are: that’s why I am firing my family medicine board. The expense does not provide sufficient benefit for my patients. It is a bad investment. The return simply is not there.

I did get certification through the National Board of Physicians and Surgeons https://nbpas.org/. I did this mostly to support this board in hopes that it will be become recognized where board certification is required (primarily through hospitals and insurance programs, which I don’t play with anyway).

I just want everyone to understand that since I now work solely for my members—not a hospital system, not any insurance companies, not any governmental bodies—I have to consider every payment and every obligation, weighing whether it is worthwhile and beneficial for my “employers.” And I’m willing to bet not one of them cares at all whether I have that ongoing American Board of Family Medicine certification or not.

But they DO care whether I would end up having to increase my fees in order to continue to dance to that music.

So, you will no longer see the words “Diplomate, American Board of Family Medicine” below my name on my business cards. I will be taking down the framed paper that states I have re-certified through 2016. And I won’t have to increase membership fees.

I hope that you all, as my employers, agree with my decision

Change

“Change is the law of life. And those who look only to the past or present are certain to miss the future.” ~ John F. Kennedy

No one really likes change. Some may claim they want or welcome change, but there is something within them that wants to cling to the present, or the past. How many times have you thought to yourself, “But we’ve always done it this way!” Don’t worry; it’s natural to resist change. But understand this: change IS the law of life. Everything changes; hopefully it is in small, easily-digestible bite-size pieces, because we accommodate more change when it is slow and barely noticeable.

Think of the (usually) slow transition of the seasons, or the budding and then flowering of fruit trees. Eventually that bump at the base of the flower becomes a pear, or an apple. If one day there were bare branches and the next day full ripened fruit, how magical it would appear to us, though the same end is accomplished through the gradual process of growth.

I sense we are on the cusp of some big changes—in our neighborhoods, our state, our country, and in our world. I’ve told more than one of you “It’s going to be a long, hot summer,” and I mean more than just the weather. When so many different things are teetering on the edge, change is inevitable. Whether for better or for worse is anyone’s guess, and subject to their own perspective.

The Affordable Care Act started a wave of change in the medical world that continues to have an impact on patients and physicians and medical care workers daily. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2013 will change how physicians are paid, especially with the recently disclosed 952-page rules on payment. The very physician organizations that heralded that bill as the “Doc Fix” are now complaining that this will bankrupt the vast majority of independent physicians and are “demanding” the rules be changed. That will not happen any more than will Congress repeal or replace the ACA. These changes will impact American medicine for years, if not generations, to come. Locally, here at the Lake of the Ozarks, a major hospital chain has pulled out and left their clinic (and its patients) stranded. Sure, patients can travel 30 minutes or more to go to one of their other clinics, but they will NOT be able to “keep their doctor” as the hospital system has stranded him as well. He will now be an independent physician, but if he intends to bill Medicare, the rules of MACRA will actually punish him for being independent! How long can one tread water?

Meanwhile, we soldier along here at Direct Primary Care Clinics, serving our members regardless of their insurance coverage, or lack thereof. I anticipate a day that Medicare will not cover the medications I write for Medicare patients, and when that day comes I am sure we will find a way around that roadblock too. Because that is what change does—it forces one to either conform or to find creative alternatives.

Here’s to creative alternatives!

 

 

 

 

Precious Privacy

What a human tendency it is to deny that we have anything “to hide!”  Does this mere sentence cause your self-defensive hairs to rise? It should, because we all have something precious to “hide,” something we take for granted that is the envy of millions around the world.

We all have our privacy to hide.

It concerns me that that with every new, sweeping loss of our privacy no one seems to bat an eye. Oh we might complain a little, or make jokes about it; but, we don’t seem to notice that little by little our precious privacy is being eroded. We have been trained to point to the attacks of 9/11/2001 and declare that if there had been better surveillance, it would not have happened.  “We can’t let it happen again,” is exclaimed.

“In the name of National Security” has become a mantra. Please, do me a favor: find someone who lived in the Soviet Union or Cuba and ask them about National Security.

It concerns me that when we see a vehicle pulled over we make assumptions. They must have been speeding, we think.  When I talk to patients who share their stories of being pulled over and having their medications with them, I cringe.  Then, I print off a copy of KrisAnne Hall’s Fourth Amendment handout http://krisannehall.com/wp-content/uploads/2014/07/fourth-amendment-facts.pdf, which explains the right to privacy guaranteed by the Fourth Amendment.

There are no local, state or federal laws that may supersede the Fourth Amendment! If they do so, they are illegal. A search warrant is required—period.  It will not be difficult to get a search warrant if there is probable cause.  But, I will leave the technical legalities to another day.

My biggest concern is the general lackadaisical attitude toward the privacy of medical records. First, to whom do your medical records belong? By right they should belong to you.

But, I encourage you to try to get a copy of your full records. Go ahead. It will probably cost you, and you’ll have no guarantee what you get includes ALL your records. By requesting a COPY of your records, you are not purging your records, either. You may be told that you have access to your records electronically, but the keeper of the records is careful to control what part of your records you may access. However, your insurance company is not so bridled; they may have full access, and do not require your written permission! Why? Because, you signed a paper signing away all your rights to privacy when it comes to your medical records! Your insurance company, the federal government, other physicians and their office personnel—basically, anyone with whom the record-keeper does business—have access to your records, as long as they sign a business associate contract.

The Health Insurance Portability and Accountability Act (HIPAA) http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/html/PLAW-104publ191.htm really has nothing to do with your privacy, though that is all anyone (including “healthcare providers”) thinks it maintains. The Department of Health and Human Services  (HHS) wants you to think that’s what HIPPA is all about as well. But realize, any law that allows the department of HHS to access your records without your knowledge is not a law about maintaining your privacy.

Did you know that you do NOT have to sign that you have received the privacy policy of the “healthcare” facility you utilize? Did you know you don’t have to answer any questions you don’t want to answer?  Did you know that HIPAA was the first step in a long line of “laws” designed to create an “interoperable nationwide health information infrastructure?”  (These are official words, not mine.)

Is there anything in that phrase—interoperable nationwide health information infrastructure—that sounds at all reassuring, that it is your privacy they are concerned about preserving? Am I the only one who immediately thinks of George Orwell’s 1984 when I merely read that phrase?

My friends, do you have any notion of what unholy behemoth we have unleashed? It doesn’t eat your soul, but it devours your medical privacy. Plus, with the re-definition of the practice of medicine to “healthcare,” your medical privacy extends to everything you ingest, breathe, wear and to which you expose yourself.  Then, because it is realized that in order to control your health, we have to control your personal habits—there you have the development of an interoperable nationwide health information infrastructure!

Yes, I can hear at least one “friend” cry, “The sky is falling!”

Oh yes my “friend”—it is.

If by sky you mean your freedom, and by falling you mean death.

I just utilized a “healthcare provider” last week.  It is someone with whom I have a real friendship, and this provider likes to have certain things in her medical records; so, I answered some things honestly.  However, there was a lot I wouldn’t answer. It is not pertinent to the issue with which I was seeking care.  I was honest and reported that I do not smoke, unless I am on fire, and that my source of caffeine use is coffee.  The amount? All of it, which is an exaggeration, but it told her what she needed to know.

And no, I did not sign the HIPAA release.

Privacy—an inherent right recognized by our Constitution—has been taken for granted for far too long.  We should never feel we have to give up some of our privacy in exchange for some security.  I am not willing to sacrifice my privacy on the altar of “security”, not for your security, nor for mine. Don’t fall for the “I have nothing to hide” trap. You have something not only to hide, but also to hoard and protect with your life: your right to privacy.

The right of the people to be secure in their persons, houses, papers and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the person or things to be seized. Fourth Amendment, U.S. Constitution.

~JPowell MD