The ABR and the Pinnacle of Flexibility

From ABR President Brent Wagner’s article, “ABR, Stakeholders Remaining Flexible During Uncertain Times,” in the May issue of the BEAM:

For the ABR, as it became clear that standard exam development activities would not be effective in the short term, staff and volunteer content experts quickly made adjustments: test assembly activities for upcoming exams were revised to use remote conferencing software. While this is often not optimal for the volunteers, the modification to the process promised to support continued success in exam creation that would be relevant and cost effective.

The real stakeholders here are the residents who should be taking a live-proctored test from the comfort of their home next month.

The volunteers who do the heavy lifting of test creation may have been given the flexibility to volunteer from home, but so far the ABR has been unwilling to “remain flexible” enough to do the right thing and make remote testing a reality like the American Board of Surgery recently successfully demonstrated. Even the NBME has temporarily canceled USMLE Step 2 CS with the understanding that nationwide travel is simply inappropriate for a healthcare-related examination involving scores of doctors for the foreseeable future.

Some financial considerations are almost certainly tied to this desperate need to have a live in-person exam that no one has ever wanted, but departing highly-compensated Executive Director Valerie Jackson said this in her departing missive:

Another big part of my life has been volunteering. Over the years, some of my friends have wondered why I would give so much of my time for no pay. The reward isn’t monetary; better than money for me was the sense of giving back, the ability to work with wonderful people who are now long-term friends, and having an impact on many facets of our profession.

I have no words. Total compensation in 2018? $834,567.

I did, however, like the final paragraph of incoming ABR President Robert Barr’s entry:

We still have work to do. We need to keep costs down, we need to ensure that testing is meaningful and accurate, and we need to improve the overall test experience for our candidates, among other challenges. We are working on all of these today. I hope you’ll give us a chance, and I welcome your suggestions and constructive feedback.

I would love nothing more than for the ABR to pivot and start making the correct operational and strategic decisions to succeed in those areas. The ACR recently made some suggestions.

Symbolic Measures and the Silence of the ABR

Earlier today the ACR passed resolution 50 without dissent, a gesture made in response to the recent (and ongoing?) MOC agreement debacle. The thrust of the resolution is that the American Board of Radiology should strive to “minimize power imbalance in decision-making between those professionals and the certifying body by committing to representative, inclusive, and transparent decision-making.” Also that they should consult the ACR before making terrible participation agreements and should also share said agreements in advance for public comment from candidates and diplomates.

Little birdies informed me that the ABR was working hard behind the scenes to spike this resolution. However, when it was presented during the reference committee hearing on Monday and then came up for a vote today, the ABR maintained complete radio silence. Not a peep.

This is, oddly, in strange contrast to recent promises of greater communication and transparency, such as when the ABR President recently said he wanted to “take ownership of flawed or incomplete communications.” Given the opportunity to literally address the entire radiology community and its largest deliberative body, the ABR didn’t say anything. They didn’t argue that they were right. They didn’t admit that they were wrong. They offered no window into the agreement process or any public acknowledgment or response to the many questions and comments that are contained in the resolution or that were raised during the discussion.

Why?

Because they don’t have to.

The core problem with the ABMS member boards like the ABR is that they are completely unaccountable. They may claim “business league” nonprofit status as 501(c)(6) organizations, but they are not accountable to their fields or their diplomates. The ACR has no power over the ABR. So why should the ABR work with them? Why subject itself to a public flogging? Better for that to occur on Twitter, anonymous forums like Aunt Minnie, and yes, right here.

During the reference committee discussion, I offered this testimony:

In its recent apology email to diplomates, the ABR suggested that the new MOC agreement was a slip-up. They wrote, “an error in the creation of the agreement resulted in the posting of an incorrect document, with more restrictive language than was intended.” This statement is at best misleading. The document was not simply a one-off overreach. I would like the members of the college to know that I and all other recent diplomates have been forced to sign similar agreements during our training. I signed a nearly identical agreement waiving my own due process rights in 2013 when I was a first-year resident. And today, despite softening the language of the recent MOC agreement after the public outcry, the current Candidate Agreement containing the exact same problematic language remains completely unchanged. We are leaving our most vulnerable colleagues out to dry.

The ABR is currently starved of external influence and oversight. Their bylaws mandate that nominees for the Board of Governors are solicited internally and elected by 3/4 majority of the current BOG. This insular approach essentially precludes outside perspectives. Once elected, the ABR conflict of interest policy “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.”

This is deeply problematic. The ABR, by its own bylaws, is unaccountable to radiology and to radiologists. This is why we have our current state of affairs.

What we do matters. We should demand transparency and excellence from any organization that has an impact on our field and our practice. And if the ACR will not take a stand for radiologists then who will? This resolution could be a small first step toward creating a more meaningful working relationship.

Ultimately, this ACR resolution is purely symbolic.

Unfortunately, the ABR’s softening of the recent MOC agreement language was also merely a placating gesture, because it’s functionally similar despite the removal of the most heinous legalese.

There is a massive power imbalance here. In a situation where you can only vote with your feet, you have to be able to walk to wield influence. But doctors can’t strike. And the only people that can meaningfully do so in the current climate are the grandfathered lifetime certificate holders who are optionally enrolled in MOC, and they make up a shrinking fraction of the ABR’s profits every year.

Until the ABR decides that transparency and democracy will help their mission (or their bottom line), they have no need to listen.

But I hope they will. And I hope the ACR will take increasingly strong positions in future years because they’re an important part of the certification narrative that the radiology community needs to hear.

ABR MOC and the Art of the Apology

This week the American Board of Radiology emailed its diplomates in response to the continued concern that its initial fix to the over the top legalese in its agreements was buried so deep that no one could see it as well as the frustration that people who caved early didn’t have a chance to sign the new one.

I know some regular readers are getting bored of all this ABR talk—and we’ll be moving on from this flurry soon I promise—but there’s also a lot to learn here about management and organized medicine.

The ABR, clearly hoping for a gold star, started with this email subject line: “We listened to your concerns about our MOC Participation Agreement.”

Glad to hear it.

Today we’re discussing how to apologize.

Dear Diplomate:
As part of your enrollment in the ABR’s Maintenance of Certification (MOC) and associated interactions with our website, periodic renewals of user agreements are needed to codify the understanding of the limitations of usage of the materials and the extent of liability. This is especially important in establishing the security of the content used in assessment, in order to maintain a secure, valid, and fair process.

In March, an error in the creation of the agreement resulted in the posting of an incorrect document, with more restrictive language than was intended. Specifically, our request for those enrolled in MOC to waive certain legal rights was neither reasonable nor necessary.

I gave the ABR some advice on how to apologize back in 2017. When an accountable organization makes a mistake, they should:

  1. Express regret and acknowledge responsibility
  2. Be transparent and describe the mistake
  3. Give an action plan and steps to correct the problem
  4. Ask for forgiveness

They do a decent (incomplete) job of #3 and #4 in the following paragraphs. But they did a terrible job with #1 and #2.

The ABR is pretending that a Janice or Karen or Peter accidentally uploaded an “incorrect” document that was spuriously created in “error.” While we can all agree that waiving legal rights is stupid and unnecessary, this wasn’t an oversight. In terms of quality parlance such as might have been seen in the ABR’s manual for noninterpretive skills, the creation of the MOC agreement was not a “slip.” It was a bad choice and a manifestation of bad decision making.

It was deliberate. To say otherwise is ludicrous.

Especially so because this language was not new. I actually looked back at my own myABR history and saw that the same BS was in the “Agreement for Candidates and Diplomates” that I signed back in 2013, when I was a busy first-year resident unlearned in the machinations of our radiology overlords.

Perhaps the ABR was coyly suggesting that the language was unnecessary because all recent trainees have already signed away those rights. To wit, while the ABR changed the MOC agreement, they have not changed the Agreement for Candidates and Diplomates, which includes the same language.

Residents are a vulnerable population. Diplomates and organized radiology including the ACR should continue to put pressure on the ABR to fix this issue across the board. Don’t leave the trainees out to dry.

A revised document has since been implemented at https://myabr.theabr.org/moc-agreement. After discussion with counsel, acknowledging that the new language is far less stringent, this will supplant the original agreement for those who have already signed. Alternatively, these individuals may choose to sign the new agreement, but it is not required.

Now diplomates can now choose to sign the new agreement. Misuse of the term grandfathering has been avoided.

In view of the increasing administrative requirements inherent in the daily practice of medical practitioners, the ABR has an obligation to lessen such burdens whenever possible. We apologize for the error and hope to learn from it. No process is perfect, but we can and should continuously improve our processes based not only on internal quality control but also on feedback from our stakeholders, especially the radiology and physics professionals we are privileged to serve.

This is an excellent paragraph.

Sincerely,

Brent J. Wagner, MD
ABR President

Valerie P. Jackson, MD
ABR Executive Director

In short: I don’t know why the ABR is institutionally incapable of giving a real apology.

But more importantly, the ABR only fixed part of the problem. They responded to the loudest voices, but they didn’t even fix the imposition of onerous language on our youngest colleagues let alone address the problematic “processes” and organizational perspective that created it in the first place.

The ABR’s Thoughts on Doing the Right Thing

In response to concerns about exam administration, the American Board of Radiology has now released a “Statement on Delivering Remote Exams” to their Coronavirus updates page:

In response to queries, delivering our exams remotely is problematic. We have investigated many options, but the inability to adequately control image quality, the testing environment, and security would significantly threaten the fairness, reproducibility, validity, and reliability of the testing instrument across candidates.

A challenge? Sure. Problematic? A pure cop-out. To be absolutely clear, the ABR has already used remote testing in the past. It was just on their terms due to their mistake. There is nothing about ABR exam administration that cannot be effectively recreated in a remote setting, especially under these unprecedented circumstances.

We want to give exams that fairly and accurately assess a candidate’s knowledge and experience.

We’ve long since moved past wants and desires here. Nobody wants to be dealing with this, but forcing nationwide travel is by far the greatest threat to fair and accurate candidate assessment.

We pledge to remain flexible and responsive to candidate needs, and we appreciate everyone’s patience as we all go through the pandemic’s effects together.

Being “responsive to candidate needs” and also rejecting the idea of remote testing are 100% incompatible. This is absolutely a public health issue, and a head-down blinders-on approach is unacceptable for a health-related organization purporting to act in the public’s interest.