It’s been almost a year since I published a lengthy critique of the irrationality and arbitrariness of our current maintenance of certification process. I was concerned that there was no clearly articulated, evidence-based justification for these practices.
This is ironic, precisely because the underlying rationale has been an appeal to the importance of practicing evidence-based medicine. The same does not apply to the maintenance of certification (MOC) process, and therefore, what is preached (or mandated?) isn’t practiced. To date, there is still no definitive study proving that MOC and recertification exams improve physician performance.
I made the point that it made no sense that if public safety were really the main goal of recertification, then no one should be “grandfathered” and all diplomates should have to recertify. MOC should be relevant, affordable, and not onerous. I argued that peer review as practiced at Veterans Affairs hospitals and in English-speaking countries was a far more effective way of reviewing our practice and ensuring patient safety.
I also asked why my recent recertification in geriatric psychiatry, passed with flying colors, would be invalidated unless I recertified in general psychiatry. And I wanted to know why the same did not apply to child and adolescent psychiatrists. My exasperation increased to lorazepam-requiring levels, when I entered a bureaucratic labyrinth of fruitless attempts to obtain rational explanations for these anomalies from superiors in the higher echelons of the American Board of Psychiatry and Neurology ( ABPN ).
Responses, if I got them, were vague and referred to consensus at meetings by nameless committees. I was advised by one correspondent, who claimed to have been at one of the meetings, that there was to be an announcement in one of the newsletters I receive online from the American Association for Geriatric Psychiatry ( AAGP ). To date, there has been no mention of the issue, and the person who I was told by another person led the discussion could not recall that this topic had ever been discussed. (I have the correspondence to prove this.) He did cheerfully (I think) tell me that he had written both exams and that the process hadn’t been too onerous. I think he might have been trying to tell me that if he could do it without complaining, then so could everyone else.
Then I actually got to meet Dr. Larry R. Faulkner, the ABPN’s CEO, at last year’s ABPN MOC session at the American Psychiatric Association’s annual meeting in Toronto. I felt a touch of nervousness when I introduced myself as “the person who wrote to ask why the requirements were different.” For all I knew, there might have been others, but Dr. Faulkner’s eyebrows rose in a sort of recognition. We shared a joke about how relieved he was that I didn’t appear deranged. I wondered if perhaps he might have been a little disappointed, as at least he’d then have had the option of calling security.
I was able, in my most diplomatic tone – I am after all, a diplomate of the ABPN – to once again pose the vexed question about why it was that child psychiatrists were not required to maintain their certification in general psychiatry as well. This time, Dr. Faulkner did not defer to some anonymous committee at the AAGP, but said the decision was based on the fact that geriatric psychiatrists are more likely to see adult patients than are child psychiatrists. He regarded me with the assurance you’d expect from someone confident that he’d had the last word. I had no idea of the statistics, which I assumed supported his pronouncement. “I see,” I said. Dr. Faulkner smiled again. Game over.
“I’m a child psychiatrist, and I’d say about 40% of my practice is adult psychiatry” said a man next to me who had been listening to our conversation. Dr. Faulkner frowned.
“I’m a geriatric psychiatrist. I’d say about 10% of my practice is adult psychiatry,” I chirped.
Dr. Faulkner frowned again. He looked at his watch.
“Anyway,” he said.
We looked at him. He shrugged.
“Yeah, well what can you do?” he said.
We shrugged.
“Gotta go; nice meeting you,” he said.
“Yeah,” we agreed.
“I guess he gets lots of complaints,” I said to the child psychiatrist.
“Don’t we all,“ he said.
But I digress. Or maybe not. What does this all have to do with MOC? The whole debate on MOC erupted when Dr. Paul Tierstein , a cardiologist in La Jolla, Calif., organized a petition signed by thousands of internists frustrated by increasingly expensive, onerous, and irrelevant requirements by the American Board of Internal Medicine ( ABIM ). The ABIM leadership ignored its members, shrugging and equivocating and asserting its will. Once the petition was signed and the anger palpable came apologies and backtracking. Then Kurt Eichenwald of Newsweek got hold of the story. He went on to expose financial malfeasance at the ABIM. The diplomates were paying for the executives’ lavish salaries, bonuses, and perks, including a condo, with their hard-earned recertification fees. It didn’t look good.
The ABPN quickly sent out a statement proclaiming its differences from the ABIM, boasting of greater responsiveness. To prove it, the ABPN even made one of the part IV performance in practice (PIP) modules optional – the one where you get your friends and colleagues to fill in forms and give you excellent performance ratings. No doubt, ABPN officials were afraid of a similar revolt among their own members – who were snarling in the online chat rooms. But ABPN officials weren’t ready to give up – especially the lucrative parts of MOC like recertification exams and their “approved products” for the PIP clinical modules. They continued to assert that only their version of MOC was valid while implying that anyone critical of their approach wasn’t serious about maintaining their expertise.
Dr. Tierstein and his associates created a new board, the National Board of Physicians and Surgeons (NBPAS). More and more hospitals are accepting its certification, which costs much less than the ABMS member boards. Many of us have joined. I suspect more are thinking about it. The NBPAS’ main requirements are previous certification by an ABMS member board and 50 hours of CME in the previous 24 months. If your certification has lapsed, you must have 100 hours. You must be licensed and in good standing. The NBPAS is not a free-for-all but a reasonable alternative to the ABMS.
But the ABPN and other member boards are fighting back. MOC exams are alive, well, and exorbitantly priced. The application fee for the exam is $700 for a form that takes less than 5 minutes to fill in. The exam fee is $700. And the late application fee is an additional $500.
The ABPN recently sent out an enthusiastic memo with a whole new set of tasks to complete, apparently pertaining to patient safety. Who could argue about the importance of that? Except it includes topics like “corporate compliance, the deficit reduction act, infection control, and preventing occupational exposure,” which aren’t always hugely relevant in psychiatry. Anyway, the bureaucrats at the hospitals we work for are equally adept at submitting us to hours of mind-numbing “trainings” in these subjects. Who knows why the ABPN got in on the act as well? Could it be the “approved products” on sale to fulfill these new requirements?
That the ABMS member boards’ main focus is pecuniary is further suggested by the enormous compensation its CEOs and presidents receive. They may not be in the same league as Wall Street investment bankers, but they earn on average two to four times more than the doctors whom they have subjugated under the MOC yoke. For those interested, the following link is instructive. We discover that according to the IRS, our own Dr. Faulkner is well remunerated.
We are unlikely to get answers as long as the ABPN and other member boards issue directives and refuse to engage in meaningful dialogue with their diplomates. It really is about how they see their role. Is it collegial and collaborative as they like to imply with their smooth rhetoric? Or is it to regulate and control as suggested by their stonewalling and unwillingness to engage until they receive petitions from large numbers of angry members?
It will be interesting to see what will unfold as alternatives such as the NBPAS gain traction. It costs $169 to become board certified with the NBPAS.
Ironically, we already have peer review processes in university hospitals and health care systems, which really assess our performance in practice. Most doctors know that you can pass any number of multiple-choice exams and still not practice good medicine. Peer review can be done cheaply and truly reflects our clinical practice. Our British and Australian colleagues have opted for a similar approach with peer groups for mid-career psychiatrists. But one suspects that our boards will not approve activities where they cannot collect fees.
That, sadly, is the state of our MOC process. Hopefully, next year, there will be better news.
We need our own Dr. Tierstein for that to happen. Or maybe we should begin by joining the NBPAS, where he already represents our interests.
Postscript:
I had just finished writing the above article when I received a mass communication from the ABPN dated Feb.19, 2016. While maintaining Part IV of MOC, the board has now given us the option of completing either the Feedback Module or the Clinical Audit Module. So there is progress, although one can’t help wondering why ABPN officials changed their minds after previously insisting how critical the PIP modules were. What they don’t plan to do yet is discontinue the recertification examinations. And not surprisingly, the “approved products.” Ironically, Part IV, if implemented as our U.K. and Australian colleagues have done, would be far more reflective of MOC than examinations, though far less lucrative.
The other piece of good news is that on Feb. 22, we received a survey from the AAGP essentially asking what we thought of the discrepancies in recertification requirements between child and geriatric psychiatrists. Clearly I’m not alone, and implicit in the questions is a concern about geriatric psychiatrists not recertifying. (I wonder why.)
Maybe 2016 will prove to be a good year, after all.
Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.
