AOA is at Critical Point in Its History

Stuart Damon, DO shares his recent correspondence with then-AOA President (now Immediate Past President) John Becher, DO:

From: Stuart Damon
Date: April 13, 2016
To: John Becher
Subject: Re: What makes you and me different?

Dr. Becher –

Thank you for your reply. I do appreciate your response.

With respect, a HOD resolution isn’t enough. From what I have heard so far, the ACOFP has forwarded a recommendation encouraging review of OCC. Tactically and strategically inadequate. OCC and recertification both need to be done away with by immediate action of the AOA leadership.

OCC and the manner in which came into being is a symptom of a larger problem (more to follow).

There are virtually no data that compare lifetime with time-limited diplomates; I have found two such studies. Neither involved a large sample space, and both demonstrated similar results: though the marker of quality was different between the two studies, there were no differences between lifetime and time-limited certification holders.

I will categorically state that there will never be any high quality studies looking at continuous certification processes, whether we are speaking of OCC or MOC. The reason for this is simple: No certifying body can afford to allow such a study to be done, and if by some fluke, one were undertaken, the data would never see the light of day.

I can say that with such confidence because none of the three possible outcomes that derive from a study comparing lifetime vs. time limited certification on any given measure of quality; each has severe problems that a certifying board would be unhappy about having to explain:

Outcome A: no differences are found between groups. Probably the most likely result I think that most would agree; the problem for a certifying board is that this results indicts not only continuous certification, but the entire industry of recertification altogether. As a consequence, the AOA and its subsidiary boards have to explain to a generation of physicians why they have been subjected to a process that has been a failure, and their time/money taken from them to no purpose. This is the best outcome for the certifying boards. It only gets worse.

Outcome B: Continuous certification proves to be effective and time limited certification holders turn out to provide higher quality care. Cause for celebration? No! Instead of one problem involving one constituency to explain, now the certifying bodies have two problems to explain: The first problem is to explain to the public why the AOA allows second rate physicians to practice under its aegis. The second problem is to explain to the second rate physicians why they were allowed to become so. Third parties, being what they are, would savage lifetime certification holders simply because they could.

Outcome C: Continuous certification turns out to be an abject failure; time limited diplomates actually perform worse in relation to quality measures than lifetime certificate holders. Worst possible outcome for the AOA. Now there are three problems to explain – 1) to the public for why the AOA allows second rate physicians under its brand, 2) to time limited certification holders, for why they have been allowed to become second rate, and 3) to time limited certification holders, for why their time and money has been so badly ill-used. Same issue with third parties apply.

If you ask me, all three possible outcomes risk a class action lawsuit, but that could simply be fanciful thinking on my part for I am not an attorney. In truth, I am rather amazed that anyone dares to tout continuous certification as a pathway to improving quality of care – the consequences of being wrong are so severe that any certifying body in its right mind should never make such a claim.

As I stated above, OCC is a symptom of a larger problem; until the underlying issue is addressed, OCC or its equivalent will continue to plague the profession.

There are really two fundamental issues; they are interrelated.

1. The AOA Constitution lacks a system of checks and balances to restrain the actions of the BOT and elected officers. However well meaning the actions of the leadership might be, the fact is that OCC has damaged the AOA. The same sort of abuse of the power that led to OCC can easily happen again, even if OCC meets its end

2. The current procedure by which new members of the BOT are selected systematically underrepresents new in career and mid career DO’s and favors late in career physicians. There are distinct pressures and considerations unique to each stage in the career of a physician; the profession will be better for recognizing this fact and reforming its procedures accordingly.

My 2 cents – the AOA Constitution needs multiple amendments addressing Board membership, term limits, conflict of interest (consulting for the Board as a member of the Board is a bit raising of eyebrows), procedure for reversing decisions of the Board in a timely way (not 3 years to come to a resolution suggesting further study).

Aside from that, there are numerous other actions the AOA can take that serves all of the membership equally and upholds the public trust; instead of waiting for government (at the state and federal level both) to hand us something that we don’t like (such as a mandatory reporting law for incompetent practice), it seems like working on model legislation and action at the state level might be money well spent.

You have probably seen the study from last December that indicated that 1 in 4 residents will experience clinical depression during residency? Is this something that the AOA can ignore? It’s unconscionable that we allow this to happen.

Then there is the issue of physician burnout – much of the phenomenon is due to the unrealistic expectations placed on physicians by patients/families/administrators – should the AOA really be adding to the burdens borne by it’s membership (especially when the only recourse is to beg indulgence, just as I am doing now)?

A lot has been made of the idea that continuous certification processes are just another way for boards to generate revenue. I don’t know the truth of that. I do know that physicians are ultimately pragmatists; by reverting to lifetime certification, “lapsed” DO’s (physicians boarded by the other guys) may find returning to the AOA attractive. Likewise, new residency graduates may find staying with the AOA preferable, and in the era of the conjoint GME pathway, that is no small thing.

The AOA is at a critical point in its history. The decisions made now will define the profession for decades. You are in the position to do something about it (I want no part of politics, AOA or otherwise).

Thank you again for your reply,

Stuart Damon DO

John Becher  wrote:

Dr. Damon:

I believe a resolution is coming to the
House of Delegates concerning OCC.

John Becher, DO

On Friday, April 1, 2016, Stuart Damon   wrote:
Dr. Becher –

I hope that I may be able to prevail on your time for a few minutes? I realize that you are busy and probably hear a lot from we foot soldiers of the profession.

I am concerned by Osteopathic Continuous Certification (OCC) on many levels –

From the perspective of a AOA member on the front lines, without access at all to the halls of power, the process by which OCC was decided upon lacks transparency and lacks legitimacy, as it did not include the consent of those subject to its dictates.

Having spent considerable time in determining if there is any scientific evidence for OCC’s (and continuous certifications models in general), I am forced to conclude that there is simply no evidence pertaining to such models, neither favorable, unfavorable or indifferent.

In relation to the action of the BOT establishing OCC, the Board seems utterly tone deaf to me; the burdens borne by ‘young in career’ physicians are unlike those borne by any other generation of DO’s. OCC is burdensome in both time and treasure and is based on the assumption that participation will improve quality of care. Again, there is no such evidence. Why would any group of physicians ever think to create a process by which they would themselves be left behind, while others move forward in the realm of quality of care, the gap ever growing?

The data of effect of recertification on adherence to standard of care are scant. In summary, there is no difference between lifetime certified physicians and time-limited certified physician with respect to standard of care. If any effect were ever demonstrated, one must presume that for recertification to have any meaning whatsoever, physicians required to recertify would demonstrate greater adherence and better outcomes that their lifetime certified peers. Again, why would any group of physicians allow such a dichotomy to emerge?

The little data addressing quality of care and certification addresses differences between certified and non-certified physicians, not physicians who hold board certification, irrespective of duration of certification.

A huge mistake was made by prior Trustees when lifetime certification was allowed for some, but not others. The implication of requiring recertification is that recertification is germane to and improves the practice of physicians, thereby assuring the public trust. The only other reason that recertification could conceivably be established would be for monetary gain to the certifying body, a circumstance that I consider unlikely and dubious.

The result of the schism created in 1997 is that there are 2 classes of physicians – the privileged class of the lifetime certified and the underclass of holders of time-limited certifications. By mandating OCC for the latter and not of the former, the BOT not only confirmed the existence of the privileged class, but further entrenched that class as such.

I know the argument – physicians holding lifetime certification have a contract with their certifying boards that is sacrosanct. I find this to be sophistry of the purest form.

Every physician or surgeon certified under the auspices of an AOA subsidiary board from March 1997 to the present day has an active contract with his or her member board. Though I have not been able to ferret out an exact number from the resources I have been able to access thus far, my sense is that number is about 40,000 DO’s.

On January 1, 2013, the action taken by the AOA BOT violated the contracts of every single one of those 40,000 diplomates by retroactively applying new standards to every existing contract governing existing board certificates.

So here is my question:

Accepting that it is indisputable that DO’s in both the privileged and underclass merit board certification, what did grandfathered physicians do to merit lifetime certification?

The answer is nothing.

The difference between both groups is an accident of timing and nothing else.

Please do the right thing and dismantle OCC, or at the very least, suspend it indefinitely. Even better, act on the evidence and convert every current certification to lifetime and do away with recertification altogether. Work on other initiatives that will benefit both the public trust and all members of the AOA equally (I have several ideas in mind if you care to hear them). Ease the burdens carried by young in career physicians; OCC only adds to them and does so without benefit to anyone.

The AOA is in need of fundamental change in the manner in which leaders are identified and advance. OCC is not evidence of good leadership. It is precisely the opposite and serves only to uphold a bankrupt status quo. I do not want to leave the AOA, but find myself contemplating doing just that.

Thank you for your time,

Stuart N. Damon DO

PS – you are absolutely free to share these sentiments with anyone you choose and to attribute them to me in so doing. I have no fear of retaliation or adverse consequence at the hands of my fellow Osteopathic physicians

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