A Deep Dive into the Bylaws of the American Board of Radiology

In this post, we’re diving deep into the bylaws of the American Board of Radiology and picking out some choice quotations for perusal and discussion. Consider this part two of a two-part series (with the first being this enjoyable analysis of the ABR’s tax returns).

You can download a word document of the ABR’s Bylaws in their entirety here. They were apparently last approved by a unanimous vote on October 20, 2017 (suggesting that the April 18, 2016 date on the current bylaws webpage is wrong).

The Party Line

For a bird’s eye view of what the ABR thinks the ABR is trying to do, look no further than Article II: Objectives and Purposes:

The objectives and purposes of this Corporation shall be as follows:
(a) To serve patients and the public by continuously promoting the competence of its diplomates;
(b) To improve the quality and safety of our disciplines through our requirements for primary and subspecialty certification;
(c) To create and conduct fair and valid examinations in our disciplines to evaluate accurately the qualifications of voluntary candidates for ABR certification;
(d) To issue certificates to qualified and competent candidates in the specialties and subspecialties of the ABR;
(e) To promote lifelong and continuous learning, professional growth, quality and competence through its MOC programs;
(f) To provide and administer programs for the Maintenance of Certification (MOC) of our diplomates;
(g) To promote professionalism within our disciplines;
(h) To establish and promote open and transparent multi-directional avenues of communication with our diplomates, medical societies, governmental and non-governmental agencies, and the public;
(i) To do and perform all things necessary or incidental to the foregoing objectives and purposes.

a) I think “promote” is probably the wrong verb. It suggests that the ABR serves patients or the public via marketing as opposed to something substantive. (Oh, I see what they did there.)

b), c), and d) are laudable goals that are unverified and hotly debated. e) is implausible. f) is factually undeniable. g) certainly not. h) transparency is not in the ABR’s vocabulary. Recent “multi-directional” communication has gone something like this:

ABR: Just trust us.
Everyone: Why would we?
ABR: Guys, we hear you, we are you.
Everyone: We don’t really see an empirical basis for that supposition.
ABR: Oh well. Worth a try. PS Your dues are due.

The Details

Section 4.3. Election of Governors. Nominees shall be solicited from the Board of Trustees and Board of Governors, and may be solicited from any appropriate professional organization. Professional organizations shall provide such nominations in writing. An affirmative vote of at least three-fourths (3/4ths) of the entire Board of Governors shall be necessary for the election of any nominee to the Board of Governors.

If you didn’t know, there are currently 8 Governors, and they basically run the show. Lincoln’s famous “team of rivals” approach this is not. The current people in power shall nominate their replacements and other organizations may, but the key for any hopeful member is making sure that you fit in with the cool kids, essentially guaranteeing that no one with substantially differing views would ever make it to the upper echelon.

 

Section 4.6. Conflicts of Interest. It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by a Governor serving on the Board of Governors of this Corporation requires the Governor to act in the best interests of this Corporation, even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member. Consistent with a Governor’s duty of loyalty, a person serving as a Governor of this Corporation does not serve or act as the “representative” of any other organization, and his or her “constituency” as a Governor of this Corporation is solely this Corporation and is not any other organization or its members.

This is an impressive statement. Read it twice and digest.

The people who run the ABR and make strategic decisions are bound to serve only the ABR and to act only to benefit the ABR. No other constituency matters including the discipline of radiology itself. Essentially, any benefits to other groups or the diplomates should be coincidental. Formalized organizational input such as from the ACR? No. Opinions of program directors, residents, fellows? No. Best interests of the patients? No.

To me, this is the exact opposite of how a certification board should function. It should be a team of stakeholders representing all relevant interests and acting to better the field. That’s the only way to ensure that it can actually achieve its mission (at least as stated in Article II).

 

Section 4.9. Officers. The officers of this Corporation shall consist of a President, a President Elect, and a Secretary-Treasurer, each of whom shall be a member of the Board of Governors, and such officers as the Board of Governors from time to time may elect…

The head leadership can only be selected from within the ranks of the cabal.

 

Section 5.1. Board of Trustees. The Board of Governors shall create a Board of Trustees, a strategically selected body that advances the quality, relevance and effectiveness of the American Board of Radiology’s examinations and programs for Certification and Maintenance of Certification across all disciplines of Radiology. The Board of Trustees is responsible for making operational decisions, subject to review by the Board of Governors, including but not limited to, examination goals, format, content, assembly, delivery, scoring and feedback.

There are currently 18 Trustees. I’ll admit I’m naive here, but I’m not exactly sure why there are both a head-board and a separate under-board. This seems like people just passing on the hard operational work to a group of subordinates via mandate while they get to chill and make “strategic” decisions.

 

Section 5.3. Terms, Term Limits. All members of the Board of Trustees shall serve for the limited period provided. Individuals may be nominated by any member of the Board of Trustees, which may solicit appropriate professional organizations to provide candidates. An affirmative vote of at least three-fourths (3/4ths) of the entire Board of Trustees shall be necessary for selecting a nominee. All such nominations must be approved by the Board of Governors.

Continuing a trend, the current trustees nominate and elect their own replacements, but the Governors have veto power should any organization put forth an unacceptable candidate. Neither the Board of Governors or the Board of Trustees are deliberative bodies.

And how could that change, unless the ABR determined that becoming democratic served the best interests of the ABR itself? Anything else would demonstrate insufficient loyalty.

 

Section 6.1. Annual Meeting. There shall be an annual meeting of the Corporation held during each calendar year at a time and place to be determined by the President. The Board of Governors and the Board of Trustees will meet both separately and together at the annual meeting; the timing of combined meetings will be determined by the Board of Governors. Members of the Board of Governors may regularly attend the Board of Trustees meetings as determined by the President.

Apparently that place is Hawaii.

 

Section 6.2. Regular Meetings. Each Board may hold regular meetings at such place and time as shall be designated by the President. The Board shall transact such business as may properly be brought before its meetings.

Apparently that place is also Hawaii?

 

Section 6.4. Conduct of Meetings. Unless otherwise determined, all meetings of the Board of Governors or the Board of Trustees shall be conducted in accordance with Robert’s Rules of Order, Newly Revised. Every meeting of the Board of Governors shall be presided over by the President, or in the absence of the President, by the President Elect, or, in the absence of the President and the President Elect, by a Governor chosen by a majority of the Governors present.

Close your eyes and picture the lameness. Is there a second?

 

Section 7.2. Committees of the Board of Governors.
a) Budget and Finance Committee. The Secretary-Treasurer shall be assisted in his/her duties by a Budget and Finance Committee, which, in addition to the Secretary-Treasurer, shall consist of at least three Governors. The Secretary-Treasurer will serve as the chair of the committee. The duties of the committee shall include reviewing the annual budget, overseeing investments, recommending examination fees, reviewing personnel salaries and benefits and related matters as assigned by the Board of Governors.

What I would give to be a fly on the wall during this committee’s meetings.

 

b) Bylaws Committee. The Bylaws Committee shall be responsible for reviewing the Bylaws and recommending appropriate modifications in them to the Board of Governors. The Committee shall consist of three Governors, as well as a Chair appointed by the President. The Chair of the Board of Trustees shall serve on the Bylaws Committee.

I initially assumed that shady COI stuff was standard jargon, but apparently this document has its own committee.

 

h) Executive Compensation Committee. The Executive Compensation Committee will carry out the Board’s responsibilities for designing, managing and annually reviewing Executive compensation and the Executive compensation policy. This committee will consist of the President, President Elect, and at least one additional member from the Board of Governors appointed by the President. The President will chair the committee.

I love that the committee that handles executive compensation is chaired by the president and then attended by the president-elect and “at least one additional” presidential appointee. Good thing that a conflict of interest for the ABR is just when a Governor cares about something outside of the ABR.

 

Section 9.1. Revocation of a certificate or placing a diplomate on probation.

There are a bunch of reasons the ABR can revoke your certificate. They all seemed reasonable, and I’m not reprinting them here. I read them pretty carefully and was relieved that writing critical sarcastic posts on your personal website was not listed.

 

ARTICLE XIII Indemnification of Trustees, Officers and Others. The Board of Governors may exercise the full extent of the powers which this Corporation has under the laws of the District of Columbia, as such law exists from time to time, to indemnify members, Trustees, Governors, officers, examiners, employees, including the Executive Director, Associate Executive Directors, volunteers, and agents for expenses incurred by reason of the fact they are or were Trustees, Governors, officers, examiners, employees, including the Executive Director, Associate Executive Directors, volunteers, or agents of this Corporation. Such expenses shall include attorneys’ fees, judgments, fines, amounts paid in settlement, and amounts otherwise reasonably incurred. The Board of Governors may make advances against such expenses upon terms decided by it. The Board of Governors may exercise the full extent of the powers which the Corporation has under the laws of the District of Columbia, as such law exists from time to time, to purchase and maintain insurance against the risks above described, on behalf of its Trustees, Governors, officers, examiners, employees, including the Executive Director, Associate Executive Directors, volunteers, and agents.

Imdemnify is legalese for covering personal liability expenses, so this is saying that the ABR may cover fines, legal fees, settlements, etc that its brass could otherwise be accountable for due to their actions relating to their work for the ABR. The ABR’s got its own back.

While none of its members have been personally named in any suit that I know of, it remains in perfect irony that the inflated certification fees the ABR collects are absolutely funding the defense against a class-action lawsuit about those very same fees.

Summary

So those are the highlights.

That COI policy would make more sense for a Fortune 500 company, and that executive compensation “committee” sounds farcical.

I personally find the ABR to be a silly but mostly innocuous presence in my life. Yes, they charge too much and provide too little, but frankly, I find the NBME’s influence in medical education and price gouging to be much more problematic for the medical profession. I didn’t personally struggle with the Core Exam, thought the Certifying Exam was a joke, and felt that the worst part of both experiences was taking me away from my family and young children for the travel. MOC is nonsense. OLA took me less than one hour spaced over the course of eight months to complete my annual requirement, and my group reimburses for the expense, so it cost me nothing. The issues with MOC are predominately ones of principle.

My point is that my criticism here and elsewhere doesn’t stem from personal bitterness. I am young and trained in the era of the Core Exam. I didn’t get switched midcycle from the ten-year plan to continuous MOC, losing out on years of earned respite. I don’t personally begrudge the very idea of MOC, and I can certainly understand the goal of initial certification in making sure that practicing radiologists are in fact safe to practice radiology. I don’t care if the ABR exists, I just want them to exist better.

My beef? I think the ABR is operationally immature. They make juvenile mistakes, ill-informed decisions, and deliver a generally subpar product. And they either don’t realize it or simply don’t care.

The ABR’s outreach to its constituents is composed mostly of attending radiology meetings where they don’t meaningfully address common concerns and releasing a newsletter that is 90% transparent propaganda. In their collective mind, the ABR knows what we want and is giving us more (from the recent BEAM newsletter):

Starting in November, publication frequency of The BEAM and several formatting and content enhancements will occur. We are embarking on a six-times-per-year schedule instead of three times per year to help us remain more current with important news…We’ll be including short write-ups about people who work for the ABR, so diplomates and candidates can get a better idea of who’s here to serve them. The first is on the Certification Services tam [sic].

Spell check is a rough mistress.

This is almost certainly because ABR self-selects its leadership from…dedicated…volunteers. I estimate a 0% chance that anyone with radical ideas or a desire to change the status quo would be selected. And, unlike many professional societies, the ABR top brass aren’t exactly unpaid volunteers.

Conclusion

I suspect that the ABR is composed of smart, caring, and dedicated individuals who probably want to do the right thing. But as an organization, the blinders are on and groupthink clearly reigns.

I suspect that–from within–the ABR feels misunderstood, that they are doing their best to carry out their mission in an imperfect world where there are no perfect tests and drawing sharp lines feels like a messy process.

But the ABR is not misunderstood.

Instead, it functions within a meticulously-crafted bubble with its own reality-distortion field, preventing its leadership from seeing where things went wrong and where they’re going.

What bugs me?

It’s the pettiness.

It’s a few doctors doing things on behalf of constituents without their input and against their wishes, flaunting their mandate, slinging meaningless slogans, and appearing to profit in transparent and frankly embarrassing ways.

Our profession deserves better.

Guesting about PSLF on the Financial Residency Podcast

Listen to me and Ryan Inman of the excellent Financial Residency podcast nerd out about PSLF and why you should 1) be diligent and 2) ignore the clickbait/majority of what you read online.

Check it out.

I would normally give the disclaimer that I had a cold, but I have a four-year-old and now an infant in daycare, so I’m always either sick, recently sick, or about to be sick. Clearly my verbal tick of the day was “at the end of the day,” so mentally subtract that from your listening and it’s a great episode!

Dealing with Test Anxiety and Demoralization

For as long as I’ve been taking multiple choice question tests, I remember when I’d get a question wrong, a lot of the time I would say:

Oh wait, that doesn’t count, I really knew that one.

But the fact is that there’s more than one way to get a question wrong. Most people think of really being “wrong” as when they’re totally clueless, but that makes up a minority of cases. Many times you will actually know the learning point being tested even when you get the question itself wrong. You got the question wrong because you couldn’t link up the facts you know with how they’re requested through a question stem. Other times you went too fast or got played by a plausible alternative choice. Those are good reasons for why doing high-quality practice questions is a critical component of any exam prep: you need to continually pair up facts in your brain Rolodex with answers as framed on multiple-choice questions. It takes time, and there’s no shortcut.

One of the difficulties some of my former students had with studying through questions is that getting questions wrong is demoralizing. And if you’re using questions relatively early on in your developing mastery of the subject matter, you’re going to get a lot of questions wrong. I would encourage you to consider this bottom line: when you’re studying with any qbank, your goal isn’t really to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong. You need to see the information in its “native“ environment.

Demoralization and test-anxiety

Unfortunately, for many students, this process of demoralization and self-doubt feeds into test-anxiety. For high-stakes tests like the Step exams, that dread could easily ruin months if not years of your life. It’s a hard cycle to break.

One thing I believe (and I do mean believe, no science/data here) is that when it comes to performing on the big day, the more you care, the worse you do. If each time you’re not sure about an answer shakes your overall confidence, it’s going to be a very long test. Being blindsided by a question doesn’t make you an idiot. Derealization is a helpful skill, because dispassionate nonchalance is a better mindset than “this test determines my future.”

So, you need to start by not beating yourself up. Your specific goal of [insert high number here] is awesome and I hope you get it, but you need to know that goals are only helpful as a means of motivation. Not something to tie your entire self-worth into. When you check your performance and get demoralized, you are doing yourself a disservice. A friend’s performance, peoples’ posts on SDN—absolutely none of that matters.

When you get questions wrong, flag them and do them again. There are lots of reasons to get questions wrong and you need to approach the explanations as a chance to learn, not a chance to be disappointed.

I want to repeat that. The reason a high-quality qbank is such a good tool is twofold. 1) Your knowledge is only helpful (in this narrow artificial context) if it helps you answer a question. The best way to see how to apply it to a question is with a question. 2) The explanation teaches you both the key facts, additional competing/confounding information, and the context/test-taking/pearls/trends/etc.

A lot of people shortchange themselves on #2. They rush through with a focus on getting through them to get more volume instead of savoring the explanations. They get upset when they get a question wrong and don’t use it as a learning opportunity. You should almost want to get questions wrong because then it means you have an opportunity to improve, a potential blindspot to weed out. (Okay fine no one wants to get questions wrong). It’s depth, not breadth.

Emotional valence and overreading

The flip side is when people use that negative emotional valence from being wrong to overread the explanation. They take an exception and turn into a new rule. They generalize too much and try to apply something specific on one question as a generic teaching point to another question where it doesn’t apply (“but last time I guessed X and it was Y; this time it’s X, wtf!”). All of this comes from stress and self-doubt.

Remember, learning is a process. Stop paying so much attention to how you’re doing. Whether you do bad or good or your score changes with each practice exam doesn’t really matter except to help identify things to learn. This is how you’re going to study and you’re going to embrace it. You’re going to take the test one day and do your best on it. Agonizing over the data on the way is just self-flagellation.

As you get close to game day, you can switch to timed blocks to simulate the exam. Get into a groove. Find the confidence to go with your gut, not agonize, not get stressed by a long question stem, etc. If one particular thing seems like you’ll never learn it, then don’t. Your score on any exam you take in your whole life will never hinge on a single topic.

The most intimidating part of taking a high stakes exam like the MCAT or USMLE may be your nerves more than your fund of knowledge.

Reframing anxiety as excitement

During your dedicated review, one way to avoid burnout is to work on reframing your attitude from fear to excitement.

Anxiety is different then dread. It was going to be a disaster, you would feel dread. The fact that you are anxious means there’s a chance it might go well.

Telling yourself that you’re calm or to calm down does not work. You aren’t calm, you can’t calm down. At least not before the event starts. Heightened awareness is a sympathetic response, it cannot simply be tamped down with a little wishful thinking. But that heightened response can be reappraised. When you feel something you don’t like, don’t fight it: re-label it. Consistently.

So.

You’re doing this so you can learn, and–before you know it–you’ll be done.

That is astoundingly exciting. It’s a huge milestone.

You need to study, do your best, and be proud of yourself.

Budget and law proposals don’t matter: PSLF will work for people who already have loans

If you took out federal student loans after 2007, the master promissory note—the legal contract between you and the US government—had this buried in it:

A Public Service Loan Forgiveness (PSLF) program is also available. Under this program, we will forgive the remaining balance due on your eligible Direct Loan Program loans after you have made 120 payments on those loans (after October 1, 2007) under certain repayment plans while you are employed full-time in certain public service jobs. The required 120 payments do not have to be consecutive. Qualifying repayment plans include the REPAYE Plan, the PAYE Plan, the IBR Plan, the ICR Plan, and the Standard Repayment Plan with a 10-year repayment period.

That’s the part that makes your loan eligible for PSLF if you meet the requirements. You’ll notice there are no loan amount caps, needs testing, or other caveats. The program is in the fine print.

And this is precisely why every budget proposal from Obama (who wanted to cap the forgiven amount) and Trump (who wants to cancel the program) has specified that any change would affect new borrowers. (This is not to mention the variety of recent Democratic presidential candidate proposals to dramatically expand student loan forgiveness).

Who is a “new” borrower? Basically someone who borrows money after the law is created and doesn’t already have older loans. To illustrate how the feds have used this term in the past, look no further than the language in the MPN regarding the Pay As You Earn (PAYE) repayment plan.

The PAYE Plan is available only to new borrowers. You are a new borrower for the PAYE Plan if:

*(1)* You had no outstanding balance on a Direct Loan or a FFEL Program loan as of October 1, 2007, or you have no outstanding balance on a Direct Loan or a FFEL Program loan when you obtain a new loan on or after October 1, 2007, and

*(2)* You receive a disbursement of a Direct Subsidized Loan, Direct Unsubsidized Loan, or student Direct PLUS Loan (a Direct PLUS Loan made to a graduate or professional student) on or after October 1, 2011, or you receive a Direct Consolidation Loan based on an application received on or after October 1, 2011. However, you are not considered to be a new borrower for the PAYE Plan if the Direct Consolidation Loan you receive repays loans that would make you ineligible under part *(1)* of this definition.

Now, even the legal nuances may all be moot for at least the short term, because democrats have been more interested in expanding loan forgiveness than canceling it, and most of the gazillion of the current presidential candidates have been trying to promote free college. With Democrats controlling the house, the chances of PSLF being destroyed in the short term are pretty low. Congress couldn’t even get this done with republican majorities in the house, senate, and a sitting president.

Now, in a couple more years in when the forgiven amounts balloon, the issue may come to a more heated debate no matter who is in charge. Because the overall student loan situation, PSLF or not, is untenable, unsustainable, and rapidly robbing young Americans (and thus the future of our country) of their chance at economic prosperity. Something has got to give.

But to give you an idea of how not imminent this is, keep in mind the Republican congress passed a temporary expansion of the existing program to help people who didn’t read the fine print.

However, the long-term health of the program is irrelevant if you’re already in school. Because the changes, whenever they come, should not affect you.

Websites and news outlets love to play up PSLF-doom-stories because they make for great clickbait (and also encourage private refinancing referrals from which many of them profit). But the clear take-home message from both the MPN and political proposals is that it does not matter what happens to the program if you’ve already made the decision to borrow money for school based on the program’s existence. When people rely on a program, you can’t pull the rug out from underneath them (not just because it’s unfair, it’s actually illegal).

And, for the hyper-cynical among you, when Trump’s Department of Education tried to do so in a very limited fashion recently (by retroactively denying some lawyers who fell into a gray zone of non-501(c)(3) nonprofits that must be approved on a case-by-case basis), the courts shut them down pretty robustly. You can’t change the rules of the game if people are already playing.

Goals and Consequences of Private Equity

A couple of interesting reads from Matt Stoller’s BIG newsletter about private equity. Given the current flood of PE group buyouts and market consolidation in healthcare, it’s not hard to draw parallels between radiology practices ten years from now and what happened to Toys R Us in 2018 or to identify the obvious issues that arise over the long term when the frontline and c-suite have zero overlap.

From “Why Private Equity Should Not Exist

The goal in PE isn’t to create or to make a company more efficient, it is to find legal loopholes that allow the organizers of the fund to maximize their return and shift the risk to someone else, as quickly as possible.

From “WeWork and Counterfeit Capitalism

Across the West, the basic problem of a corrupted productive process is becoming a quiet crisis. The reason is simple. The people that do the work in organizations are increasingly excluded from the decision-making about the work. That is why Boeing is losing its ability to build planes, why we can’t build infrastructure, and why New York City is on the verge of disaster.