ABMS and FSMB Violating the Principle of Legitimacy?

DavidGoliathMalcolmGladwellI finally read Malcolm Gladwell’s new book “David and Goliath: Underdogs, Misfits, and the Art of Battling Giants.” It was a Christmas gift from my wife. I could see how Gladwell’s theme applies to the conflict between physicians and the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB) over Maintenance of Certification (MOC) and Maintenance of Licensure (MOL). These large boards are now being called the “4th branch of government,” by those of us who are committed to the principle of lifelong learning but opposed to MOC and MOL as instruments for putting the principle into practice.

By now many people have seen Gladwell’s compelling TED video describing the biblical conflict between David and Goliath.

It’s not hard to see how David might represent physicians and the boards represent Goliath, with one obvious difference of course. Goliath is throwing David around with impunity today.

But I see our conflict as being closer to what Gladwell describes in chapter seven of Part Three: The Limits of Power [1]. Let’s have another look at one of my previous posts, The
Bristol Inquiry: Heart of the MOC?

Read again the excerpt from a medical specialty’s MOC agreement. Imagine you’re a doctor. Do you feel like a criminal? I think that’s the intent.

In Chapter Seven, Gladwell talks about the “principle of legitimacy” as it applies to those who are in positions of power. In general, we perceive an authority as legitimate according to how fair it is in wielding its power.

I don’t think a giant’s authority is legitimate when it makes me feel like a criminal. I don’t think a giant’s power is legitimate when it applies the MOC differentially to those who are younger over the older set of doctors in this country. I think a giant’s authority is not legitimate when it decides that high-level board members don’t have to abide by MOC–and pays them too handsomely.

There is so much resistance to MOC and MOL, you have to wonder about the legitimacy principle in this context. Although I don’t agree with everything the Association of American Physicians and Surgeons (AAPS) does, their lawsuit filed in Federal court against the ABMS in April 2013, whether or not it has merit, is a big clue that the giant’s power is viewed as not legitimate.

Many state medical societies have adopted resolutions opposed to both MOC and MOL, despite MOC being embedded in the Affordable Care Act law, and the Centers for Medicare and Medicaid Services incentive payment (soon to become a penalty for not complying with MOC despite the boards’ insistence the program is voluntary). There is a steadily growing number of physicians expressing resistance to MOC and MOL, which you can see at Change Board Recertification. The giant doesn’t listen, which is another way of saying that rank-and-file physicians don’t have a voice–another critically important factor which upholds the legitimacy of power.

The American Psychiatric Association (APA) candidates for the 2014 election include statements that cast doubt on the legitimacy of MOC and MOL, the most well developed one being by President-Elect candidate, Dr. Renee Binder, whose candidacy I publicly support.

I have recently sent an email letter to the Iowa Board of Medicine, the Iowa Medical Society, and the Iowa Psychiatric Society expressing my plan to send a letter to my state congressmen about legislation to keep MOL out of Iowa because I believe it will have a chilling effect on recruitment of physicians to our state. I wouldn’t consider this except that the Iowa Board of Medicine is still pursuing the MOL despite the Iowa Medical Society House of Delegates adopting my resolution to affirm lifelong learning and oppose MOL. This resolution was co-sponsored by the Iowa Psychiatric Society. Again, it doesn’t look as though we have a voice.

Remember, I support the principle of lifelong learning. You have only to look at my website to be persuaded of that. I’m also compliant with MOC. I recently paid the $1,500 application fee to sit for the Psychosomatic Medicine recertification exam, and was approved, because I’ve documented all requirements on my American Board of Psychiatry and Neurology (ABPN) Folio web page. Assuming I pass the exam, I’ll be put in the Continuous MOC (C-MOC), which is different from the 10 year MOC program I’ve been in.

Gladwell’s description of what underlies the principle of legitimacy entails a degree of consistency regarding a giant’s rules. But when it comes to the MOC, you better pay attention to the alert about the mutability of the rules:

NOTE: All policies, components, and requirements of the ABPN’s Maintenance of Certification (MOC) Program are subject to change. It is the responsibility of each individual ABPN Diplomate to remain apprised of the current MOC program requirements. Diplomates are encouraged to consult the ABPN website regularly to ascertain whether any changes have been made.

Some physicians vow they’ll not recertify if it entails all of the burdensome and wasteful activities now inherent in MOC processes. I will continue to participate, partly because my position in academic medicine requires it. This reminds me of something my wife and I discovered about tenant-landlord law in Ames, Iowa when we moved there so I could pursue my college education at Iowa State University. If the landlord (another type of Goliath) doesn’t do all that he or she ought to under the law for keeping an rental property habitable, yet requires the tenant (another type of David) to pay the rent, the tenant could write on the back of the check,

“Paid under duress.”

I wonder where in the mountain of paperwork I have to manage for MOC is the place where I can write, “Paid under duress.” And what is the weakness of this giant?

1. Gladwell, M. (2013). Rosemary Lawlor: “I wasn’t born that way. This was forced upon me.”. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. New York, Little, Brown and Company: 197-231.

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