There are separate class action antitrust lawsuits against the ABIM, ABR, and ABPN.

But there’s also a class action lawsuit against the umbrella organization, the American Board of Medical Specialities (ABMS), which names all of the member boards as “co-conspirators.” The premise is the same in all of the suits: the ABMS and its member boards have a competition-squashing monopoly on initial board certification and use that dominance to illegally tie mandatory lifelong payments in the form of MOC-fees lest doctors lose their hard-earned certifications.

There’s an interesting excerpt from a Department of Justice letter in the middle that I’m going to pull a couple of passages from (emphasis mine):

Because, like other forms of professional standards-setting, certification can become a de facto requirement for meaningful participation in certain markets, a certification requirement may create a barrier to entry. In such circumstances, certification may function more like licensing requirements – establishing who can and cannot participate in a market – rather than voluntary certification that can help patients and others distinguish on quality among a range of providers.

The more certification comes to resemble licensing, the more such industry self-regulation raises similar concerns. For example, as the U.S. Supreme Court has explained, though market participants offer important and needed experience and expertise about their practice and profession, such professionals, when empowered to set licensing requirements without meaningful review, “may blend [ethical motives] with private anticompetitive motives in a way difficult even for market participants to discern.” Similarly, competitive concerns can arise when private standard-setting processes become “biased by members with economic interests in restraining competition.” The governing members of a dominant certifying body may have incentives to set certification requirements more stringently than is necessary to certify that providers have the relevant knowledge and skills. In situations where one certifying body has become dominant, such that physicians cannot turn to alternative bodies for a similar certifying function, market forces might not constrain the dominant body from acting on these incentives.

Which is to say: the DOJ wrote an excellent summary of the current situation several years ago.

The chance of these cases actually going to a jury trial does seem a bit higher when the Department of Justice and Supreme Court have already put words on paper warning of the dangers of “self”-regulation and legitimizing the complaints against these certifying organizations.

The USMLE has “updated” the free 120 Step 2 CK questions. By updated, I mean the webpage says “updated March 2019” and the “Content Description and General Information Booklet” was revised in some way.

However, the practice materials PDF and the questions themselves are completely unchanged.

You can read my explanations for the full set from last year here.

The 2019 set was recently updated in February. Of the 117 questions in the PDF, only two have been changed, which I’ve answered below. The order and content otherwise appear unchanged, including the three multimedia questions at the end of the online version.

Please see last year’s 2018 explanations for the remainder.

The many comments at the bottom of that page may prove helpful for those with additional questions. You’re never the only one to struggle.

48. E – When people go camping, you should be thinking of zoonotic infections. Fun fact, New Mexico leads the country in cases of plague. Yes, that plague: Yersinia pestis. The “bubonic” part of bubonic plague refers to the swollen infected nodes (“buboes”) characteristic of the disease, which often involve the groin (bubo is the Greek word for groin, who knew?). In this case, they’re also describing a necrotic epitrochlear node. Classic treatment is with aminoglycosides, which bind to the 30s ribosomal subunit. (Note that Tularemia, caused by another gram-negative bacteria Francisella tularensis can present similarly but is more common in the midwest. Regardless, the two are often lumped together, the antimicrobial treatment is similar, and the answer in this case would be the same).

69. E – Catalase and coagulase-positive gram-positive cocci = staph aureus. mecA-positivity means the bacteria carry the gene that confers methicillin-resistance, hence MRSA. Of the choices, MRSA is treated with vancomycin.

Hot on the heels of last week’s anti-ABR lawsuit (which itself followed the ABIM lawsuit), two psychiatrists have submitted a very similar class action suit against the American Board of Psychiatry and Neurology (hat tip Dr. Wes). And by “very similar” I mean it’s mostly the same lawyers, it’s filed in the same Northern District of Illinois, and it really is very similar.

But the financials in question are even more eye-catching:

Between 2004 and 2017, after the advent of ABPN MOC, ABPN’s “Program service revenue” account exceeded its “Program service expenses” account by a yearly average of $8,777,319, as reported in its Forms 990 for those years. During that same period of time, ABPN’s “Net assets or fund balances” account skyrocketed 730%, from $16,508,407 to $120,727,606. In other words, at year-end 2017, as ABPN MOC revenue continued to grow, ABPN net assets (assets less liabilities) more than septupled, which included, according to its 2017 Form 990, almost $102 million in cash, savings, and securities.

$102 million. What could they possibly need a war chest of that size for? Fighting lawsuits, one presumes.

And then:

[Executive compensation includes] overly generous compensation paid to current ABPN President and CEO, Dr. Faulkner, who was hired by ABPN in 2006 as Executive Vice President, its most senior staff position. In 2007, he was paid total compensation of $500,726 as Executive Vice President. Dr. Faulkner became ABPN President and CEO in 2009. In 2017, the last year for which data could be located, his total compensation as President and CEO was $2,872,861, including a bonus of $1,884,920. Thus, as ABPN MOC revenue continued to grow, Dr. Faulkner’s total compensation almost sextupled.

No words.

Goldman Sachs analyst Salveen Richter, channeling the obvious in a note to clients (excerpted by CNBC):

The potential to deliver ‘one shot cures’ is one of the most attractive aspects of gene therapy, genetically-engineered cell therapy and gene editing. However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies. While this proposition carries tremendous value for patients and society, it could represent a challenge for genome medicine developers looking for sustained cash flow.

Ew, go on (emphasis mine):

GILD is a case in point, where the success of its hepatitis C franchise has gradually exhausted the available pool of treatable patients. In the case of infectious diseases such as hepatitis C, curing existing patients also decreases the number of carriers able to transmit the virus to new patients, thus the incident pool also declines … Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise.

Yes, franchise. Long term profits depend on the riskiness of a cure.

I’m not going to begrudge a private company their desire to make money. The possibility of windfall profits are the main reason why private companies are willing to invest in uncertain and risky biomedical research. That said, when the long tail of a too-good cure only makes tens of billions in profit, it should be hard for even a staunch capitalist to be sad.

This attitude is part of what drives fringe antivaxxers and other patients away from evil “big pharma” and the medical doctors who understand the actual practice of medicine and into the arms of pseudoscience. For my part, I don’t think any company should feel bad if they develop an HIV vaccine so effective it eradicates the disease and relieves the suffering of millions, even if it eventually results in downstream profit loss due to the loss of the chronic antiviral therapy market.

We badly need and will always need public and government research support—for many reasons—but one is because the optics of the patient as a customer mindset are so toxic.

If students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety.

That’s Peter Katsufrakis, MD, MBA, president and CEO of the National Board of Medical Examiners (NBME) and Humayun Chaudhry, DO, MS, president and CEO of the Federation of State Medical Boards, responding in Academic Medicine to a student-written article concerning how Step-prep has consumed medical education that advocated for a pass/fail Step 1.

There was a backlash, and they tried to backpedal on this comment (emphasis mine):

During the editing process of our manuscript, we added a statement about excessive use of Netflix and Instagram which was unfair and inappropriate. As leaders of the USMLE, we believe that students, medical educators, and the public deserve our respect. Our statement was inconsistent with that belief, and we are deeply sorry.

Yeah, right. Make no mistake, their glib response to actual student concerns is exactly what they meant to say. Humor is often the dull dagger of truth, seemingly softer and more palatable than direct honest communication but ultimately more damaging.

However, the disrespect is by far the lesser evil here. Students and residents are rarely respected on an intellectual level by administrators. Their perspectives are viewed as myopic and ill-informed. The real issue here is dismissal.

Students have valid concerns. Residents have valid concerns. Trainee complaints are often dismissed by their superiors as the whining of a coddled generation (whether decades ago or today), and then those graduates go on to perpetuate both the toxic culture and broken system it engenders.

The biggest problem in medical education is the uncanny ability of doctors to pay-it-forward instead of being agents of change.

President and CEO of the NRMP, Mona M. Signer, talking with Medscape:

I certainly understand why applicants and programs engage in post-interview communication, but applicants and program directors shouldn’t create their rank-order list on the basis of post-interview communication from the other party. They ought to create their rank-order list based on their true preferences. Applicants should rank the programs where they want to train in order of preference, not where they think they will match. Program directors should rank applicants in order of preference, not the applicants with whom they think they will match. The matching algorithm works best when Match participants rank each other in order of true preference.

YES. Seriously people. I would also add that people shouldn’t create their ROL based on communication (or assurances) during the interview, either.

After all these years, some students and programs still think there should be other considerations to the ROL. But there aren’t. It shouldn’t really matter what the other side wants in this system. It matters what you want. It’s your list.

From “The Residency Match: Interview Experiences, Postinterview Communication, and Associated Distress” in the Journal of Graduate Medical Education:

In terms of postinterview communication, more than 70% of respondents indicated that they wished such communication were explicitly discouraged, and more than half said they wanted programs to bar candidates from notifying them of a high rank in order to avoid match manipulation.

There are no positives to the ego-stroking, play-acting, and intermittently grossly-misleading game that programs (and applicants) play. Everyone wants to be loved and get their top choices, but the only communication that should really have any impact (or be permissible) is new information:

• My spouse early-matched to a program at your institution.
• My mother has become ill, and I truly hope to end up in your city so that I can help take a greater role in her care.
• I just won the lottery, and there is a significantly increased risk of me not completing your grueling program.

Though the NBME allows everyone to dance, the best advice will always be rank them how you want them.

Do you have any idea how many bullets I pull out of corpses weekly? This isn’t just my lane, it’s my [expletive] highway.

Pathologist Dr. Judy Melinek, responding on Twitter to an NRA tweet admonishing doctors to “stay in their lane” and stop discussing gun control.