Dissenting Board-Certified Specialist Physicians to be Silenced Under New ABMS Standards
Written by Dr. Angela Thompson, MD, MPH, FACOG, WoLF Advisory Council
On November 1, 2021, The American Board of Medical Specialties (ABMS) announced on its website that it has approved new Standards for Continuing Certification at its October 2021 meeting.
It states:
‘…the new Standards represent the culmination of three years of consultation with physicians, professional and state medical societies, consumer, and other public stakeholders from across the health care spectrum to reconceive the way specialty physician recertification is conducted. The Standards were developed following recommendations from the Continuing Board Certification: Vision for the Future Commission (Commission) which met throughout 2018 to provide strategic guidance to the ABMS BOD and Member Boards.’¹
The document itself states, on page 4:
‘To honor medicine's social contract and uphold the public’s trust, individual diplomates are expected to affirm, reaffirm, and demonstrate their dedication through the highest professional conduct in their interactions with patients, families, and all others in the health care environment.’
On the surface, this sounds completely reasonable and expected for a professional body which is the leading organization for physician board certification in the United States. Review of the actual document, however, the astute reader recognizes immediately the grave concerns with this document as a not-so-thinly veiled threat to dissenting medical opinions under the auspices of ‘professionalism,’ which: ‘...entails a personal commitment to the welfare of patients and collective efforts to improve the health care system for the benefit of society,’ (emphasis Dr. Thompson’s).
Chilling Effects on ‘Second Opinions’
ABMS and Member Boards are not regulatory bodies and thus do not have power to grant or rescind medical licensure. What the new Standards document proposes, however, is that through the lens of ‘professionalism’, Member Boards will have a channel by which to ‘develop approaches to evaluate professional standing and conduct using multiple sources’ to potentially influence the individual states’ legal and regulatory process by which physician licensure is granted or maintained. The ABMS and its Member Boards have the potential to react to any perceived ‘threat to the profession’ as resulting in potential suspension or even revocation of medical licensure.
On page 10 of the document it clearly states, under ‘Responding to Issues Related to Professional Standing and Conduct’, quote:
‘Actions against a medical license should not automatically lead to actions against a certificate without reviewing the individual facts and circumstances of the situation. A change in certificate status should occur when the diplomate poses a risk to patients or has engaged in conduct that could undermine the public’s trust in the diplomate, profession, and/or certification.’
Just how, exactly, is ‘professional conduct’ defined one might ask? Good question. It is not. One could assume in good faith that unlawful egregious misconduct or criminal conduct by a physician against an individual patient would cause suspension or revocation of medical licensure; individual state licensure boards already have the authority to determine this and act accordingly, completely independent of board certifying organizations. However, the new ABMS Standards document is attempting to team itself to regulatory licensing bodies, and does not define anything in regards to what constitutes professional conduct at all. We are left to assume, which is inherently risky and opens the door to vast interpretations of ‘professionalism’ and ‘risk’. For example, is ‘posing a risk’ to ‘the profession’ questioning any kind of medical therapy for which the science is not settled? This used to be called ‘giving a second opinion’. Under the new proposed AMBS Standards, a very common and encouraged practice of recommending and giving a second opinion on a medical treatment could be considered as a ‘risk’ to the ‘profession’ since none of this is clearly defined at all.
And what about the part of ‘professionalism’ that entails collective efforts to improve the health care system for the benefit of society? In the United States, there are many profit-based entities, such as pharmaceutical companies, medical device manufacturers, and hospitals, which serve to be benefitted by physicians keeping their mouths shut about potential abuses these systems have towards vulnerable patients. In the wealthiest country in the world, where nearly 20% of the GDP is ‘health care’ related⁴, there is a serious conflict of interest between physicians’ professional allegiance to ‘the health care system’ over individual patient needs.
External Influences on Medicine
Most disturbingly, the arbiters of what construes ‘risk’ to patients and the profession are not necessarily other medical professionals. While the Member Boards are supposed to review disciplinary actions that are reported, they are also working ‘collaboratively with key stakeholders – specialty societies, associations, patient advocacy groups, and others – to ensure that high priority population and public health needs are addressed and that advances in the specialty are reflected in their continuing education programs’.
The aforementioned statement gives much pause. Just what, and who, exactly, are the ‘key stakeholders’? The individual patient should be the only ‘stakeholder’ when physicians are exercising professional treatment decisions, but this document specifically lists ‘patient advocacy groups’ and ‘public health’. Just who and what are these groups? What constitutes public health? ABMS and Member boards were developed in their commitment to certifying that a physician’s medical knowledge and cognitive skills to serve individual patient care had met the highest bar in each specialty. The commitment to patient-centered care is the goal. While improved public health definitely can be a result of improved patient care, it has never been in the purview of ABMS boards to opine, and certainly not certify, an individual physician’s role in ensuring ‘public health’ needs are being met.
As physicians, we are trained to care for the individual patient, not the collective. This does not in any way diminish the improvement in public health which is often the result of optimal individual patient care. Let me be very clear: the role of the physician is to take into account the rights and needs of the individual patient in our care, NOT the goals and objectives of the collective. One does not need to look very far back in history to recall that there is great potential for loss of individual patient rights and bodily autonomy in the name of ‘public health’ or even worse, ‘the greater good’.
STATE STERILIZATION OF CALIFORNIA INCARCERATED WOMEN
As an obstetrician and gynecologist, the goal of what the new Standards are hoping to achieve, by January 2024, are extremely concerning. One does not need to look very far back into history to see the great harms done to vulnerable women under the auspices of ‘protecting the public’ under the ‘common good’².
Between 2005-2006 and again in 2012-2013, 39 incarcerated women in the California state prison system underwent sterilization without informed consent for this procedure. The rationale for the forced sterilizations, without consent, stretches back to a 1909 state law which was part of a eugenics campaign that ended 70 years later. An article in ‘The Guardian’ from 2021 notes that this state law ‘served as an inspiration for Nazi eugenics program’³. Under this law, state authorities were allowed to sterilize anyone in state-run institutions who were deemed to have ‘mental disease which may have been inherited and likely to be transmitted to descendants’(ibid).
Overwhelmingly, victims of this egregious medical abuse and crime against bodily autonomy and reproductive capacity were Black and Latina women. Quoting the physician who performed many of these procedures, he explained that ‘the money spent sterilizing inmates was negligible compared to what you save in welfare paying for these unwanted children- as they procreate more’². Make no mistake, anyone purporting to justify any action against one’s bodily integrity against their will under the ‘greater good’ presents a clear and present danger to humanity. Women have the most to lose, and therefore there is always the risk that there is more to ‘take’ from them: their agency, their bodily functional integrity, their fundamental human rights.
IN SUMMARY
When a specialty medical member board which is not a regulatory body steps in to try to undermine the very rights of both the treating physician and the patients in their care in the name of an arbitrary and ill-defined ‘risk’ to ‘public health’ based on not meeting another ill-defined ‘professional’ standard, as a society we should be very, very concerned. When physicians speak out against a medical practice for which there is concern for medical harm, but a ‘key stakeholder’ (not defined) alerts the ABMS and its Member Board that the physician in question is not acting in a ‘professional’ manner, we should be very, very concerned. The ‘stakeholders’ in question could be pharmaceutical companies, government agencies, or other non-clinical activist groups which have a specific agenda that may serve to actually undermine and risk individual patient health and safety.
Patients deserve the reassurance that their physician is acting in their best interest and providing care to meet their individual needs, not some ill-defined collective public ‘good’. The wording of the new Standards will have a chilling effect to effectively silence board-certified physicians from speaking out against potential medical harms and abuses at worst, or from merely having a dissenting fact-based medical opinion, due to fear of retaliatory efforts against their license to practice. The goals of the ABMS Standards for Continuing Certification document sets a dangerous precedent for potential abuses against patients and should be completely revised.
REFERENCES
American Board of Medical Specialities, Standards for Continuing Certification. 2021. https://www.abms.org/news-events/
Minna Stern, A. 2016. Eugenic Nation: faults and frontiers of better breeding in modern America. 2nd edition. University of California Press, Oakland, CA
McCormick, E. 2012 July 19. Survivors of California’s forced sterilizations: ‘It’s like my life wasn’t worth anything’. The Guardian https://www.theguardian.com/us-news/2021/jul/19/california-forced-sterilization-prison-survivors-reparations