Performance in Practice Component for Maintenance of Certification in Psychiatry

I received an email regarding the American Psychiatric Association (APA) Member Referendum ballot about the Maintenance of Certification (MOC) for psychiatrists, to be voted on by APA membership in the 2011 APA election. This was a mass email sent to all APA members.

The MOC is a response to society’s demand that America’s physicians make sure they sustain competence in their specialties in order to ensure quality medical care. The American Board of Medical Specialties (ABMS) developed the MOC, which is a program to be undertaken every 10 years by diplomates of Boards. The email was a request to vote against the American Board of Psychiatry and Neurology (ABPN) “burdensome” MOC Performance in Practice (PIP) requirements, which are slated to become mandatory by 2013 for those applying for MOC examinations in 2014.

The specific objection to the requirement for patient feedback is that it could create ethical conflicts and interfere with treatment. Furthermore, the referendum states that the requirements other than a cognitive examination once every 10 years, regular participation in medical education, and maintenance of licensure “pose undue and unnecessary burden on psychiatrists”. The sender had submitted a petition co-signed by 797 other APA members leading to the referendum.

The APA Board of Trustees Statement reminds the membership that the ABMS MOC program affects all medical specialties, not just psychiatry, that the number of patient feedback evaluations are small and only the physician would see them, that the ABPN will not receive or review any patient information, and that the APA Ethics Committee reviewed the requirement and determined it did not violate APA’s Principles of Medical Ethics with Annotation Especially Applicable to Psychiatry. The statement also points out that patient satisfaction surveys, independent of certification, are part of the health care reform bill, and that APA would continue to work with ABPN, ABMS and other organizations to reduce unnecessary burdens associated with MOC programs, and to ensure that they are consistent with high-quality patient care.

Many members of the APA believe that the MOC requirements for maintaining evidence of competence are burdensome. You can find them at MOC Program for Psychiatry .The components include:

1. Professional Standing;
2. Self-Assessment and CME;
3. Cognitive Expertise;
4. Performance in Practice.

The first 3 are viewed as manageable, although the $3,000 examination fee for fulfilling the Cognitive Expertise component is exorbitant according to many APA members. Professional Standing means psychiatrists must keep unrestricted medical licenses current. The Self-Assessment Program requires psychiatrists to demonstrate they are keeping abreast of new knowledge and/or best practices as part of an independent process of lifelong learning and career development. Programs are available to physicians to complete this component.

The sticking point is the last one, Performance in Practice (PIP). In the Chart Review module, the diplomate must collect data from at least 5 patient cases in a specific category (for example, diagnosis, type of treatment, treatment setting) from his or her personal practice over a 3-year period. Then the data must be compared with published best practices or peer-based standards (such as hospital quality improvement programs) leading to the development of a plan to improve effectiveness or efficiency. Then within 24 months, the diplomate must collect the same data again from at least 5 clinical cases, either the same clinical cases previously assessed or new ones. Obviously this has to be done 3 times over the course of 10 years.

The Feedback module of the PIP requires the diplomate to solicit personal performance feedback from at least 5 patients and at least 5 peers (which can include psychologists, social workers, physicians, counselors, and nurses) regarding the diplomate‘s clinical performance over the previous 3 years. Then the diplomate must develop a self-improvement action plan to correct inefficiencies and improve effectiveness. Again, within 24 months, the diplomate must obtain feedback from another 5 patients and peers to see if performance has improved. The patients and peers could be the same ones originally solicited. Again, this has to be done 3 times over a 10 year period.

For several years now, my colleagues and I have been required to review the charts of at least 3 of each other’s patients when we take over a clinical service. Presumably this is our internal quality improvement program intended to meet the MOC PIP requirement.

Although I’ve reviewed many of my colleague’s patients over the past several years, I’ve yet to see any of the reviews my colleagues have made of mine. I don’t know if my colleagues have ever seen my reviews of them. I don’t know who reads them (if anyone) and I don’t know how they’re used to improve effectiveness or efficiency of patient care. If they’re intended for feedback—we’re all undernourished. In fact the only inpatient ward I regularly co-staff with an internal medicine faculty member is the Complexity Intervention Unit (otherwise known more commonly as the Medical-Psychiatry Unit, probably the only one of its kind in the country). I suspect there are few other faculty members in our psychiatry department at our academic medical center who co-staff the unit nowadays who would be comfortable providing feedback to me because I’m a senior faculty member and taught most of them. I’ve never seen reviews from those who are senior to me, maybe in part because they don’t staff the unit as frequently as I do nor have they done so for as long as I have.

This is important because the feedback that would be most meaningful would be from one’s peers who have enough experience to be competent judges of one’s clinical performance.

I’ve never seen a patient survey at my institution regarding my clinical care skills, my communication and interpersonal skills, or my professionalism, all core competencies agreed upon to be critical to providing high quality patient care. The nature of my work as a Psychosomatic Medicine specialist might make getting patient surveys challenging. Many of the patients I see are delirious and are too cognitively impaired to know where they are, much less formulate a considered opinion about me.

Making the MOC PIP program work to improve patient care and physician competence needs to take into account where a doctor practices and with whom, what patient populations he or she most commonly encounters, who provides the feedback, who collects and has access to the feedback data, how much, when and where the data is stored, and what is done in response to it.

For now this is being left to provider organizations. The guidance currently provided to psychiatrists by the ABPN is restricted to one example of a PIP activity currently approved by the ABPN: the University of Wisconsin Performance Improvement-Tobacco Cessation. It’s important to counsel patients on smoking cessation—but is that an activity that would provide enough meaningful information about the practice of most psychiatrists?

%d bloggers like this: