The American Board of Medical Specialties and Maintenance of Certification

The video above is Dr. John Oldham’s February 8, 2012 address to the American Psychiatric Association (APA) membership (Dr. Oldham is the current President of the APA) about the Maintenance of Certification (MOC) program and I think he makes some very important points, one of which has been reiterated by the American Board of Psychiatry and Neurology (ABPN)–that the APA and the ABPN are following the mandate set by the American Board of Medical Specialties (ABMS) regarding the necessity of the MOC for ensuring continuous improvement in the quality of care for psychiatric patients. Dr. Oldham’s address is also available for public viewing on the APA website.

I have always agreed with the fundamental concept of the MOC, which is that individual psychiatrists should be accountable for ongoing professional improvement and improving quality of care. As it pertains to psychiatrists, the improvement is keyed to the core competencies. I would like to couch the core competencies in terms of Dr. Henry Nasrallah’s editorial about the seven domains of clinical excellence as published in the November 2011 issue of Current Psychiatry [1]. I have expanded on this a little by keying the domains to the core competencies in a recent blog post, an excerpt from which follows:

The 7 domains with my annotations are as follows:

1. Personal Attributes:

This is an extension of the core competency of Interpersonal and Communication Skills. When we  progress beyond the minimum skill of effective, efficient, patient-centered, and team-based communication with all stakeholders in the mental health care system in both the hospital and in the clinic, attaining a synthesis of engagement, empathic connection, and humility–we aspire to greatness.

2. Clinical Mastery:

This would map very well to the core competencies of both Patient Care and Medical Knowledge. Respectively, humble beginners implement the highest standards of practice in the safe, humane, and effective treatment of all patients regardless of gender, culture, or socioeconomic status while adhering closely to the research evidence base and clinical practice guidelines. A firm grounding in suicide risk assessment is an essential skill, which means including a separate risk and protective factor assessment in the treatment plan using analytic and synthetic tools to arrive at a practical, safe, and comprehensive route to healing [2]. Growing beyond this, the humble master will think both/and rather than either/or about medical and psychiatric issues, and further integrate social and spiritual concerns. Checking one’s own pulse for reactions to the patient that could interfere with understanding (countertransference) and moving toward healing will become second nature.

3. Professionalism and leadership

The trainee attains the core competency of Professionalism early on, cultivating personal characteristics consistent with high moral and ethical behavior, respect for co-workers, and collaboration with all who care for patients. Moving forward to assuming positions of leadership in the hospital,  office, national and local professional societies, and in the community to raise consciousness of the pivotal role psychiatry can play in medicine is the goal of the master clinician.

4. Organizational effectiveness:

This again maps to the core competencies of Professionalism, Interpersonal and Communication Skills, as  well as Systems-Based Practice for the trainee.  The  trainee needs to efficiently utilize health care resources and community systems to provide effective and high quality health care. For the master, organizing one’s life so as to emphasize the importance of both one’s personal health and the health of the organization for which one works is an essential skill. The humble master will learn the primacy of paying close attention to and nurturing healthy relationships at work and at home.

5. Societal Role:

Again, this reinforces the vital importance of early training in the core competencies of Interpersonal and Communication Skills and Professionalism, driving home Stephen Covey’s principles, perhaps captured most succinctly in one of his popular quotes, “Public behavior is merely private character writ large.” The master clinician will establish herself as a leader and role model because of her skill as  a communicator, not just on the wards but in society at large.

6. Lifelong Learning:

Here the core competency for the trainee of Practice-based Learning and Improvement is clearly the precursor to Dr. Nasrallah’s 6th domain of excellence for the humble master. The beginner must assess medical knowledge and technology and not just adopt new technologies and methods for patient care but constantly seek to improve them. The master will adopt a disciplined and efficient habit of searching the medical literature to answer specific questions about improving patient care and view continuing medical education (CME) meetings as avenues toward making active efforts to change one’s practice.

7. Contribution to new knowledge:

And where does scholarship map to the core competencies? Well, they may not explicitly state the importance of the scholarship of research as much as they emphasize the scholarship of stewardship of the extant knowledge. But many residency programs encourage trainees to participate in research, to present papers at national and local professional meetings, and to pursue academic careers to grow the basic and clinical science on which the provision of high quality medical care depends.

So, I think the 7 domains closely map to all of the core competencies which are fundamental and required of all trainees in Psychiatry.

What Dr. Nasrallah does (as a master clinician would be expected to do), is to develop the core competencies in the  service of helping us evolve into master clinicians.

Does the MOC PIP program help us achieve what Dr. Nasrallah so eloquently describes? I think it is debatable as it is currently structured. There is no literature I’m aware of which clearly shows that the MOC and PIP as now designed improves the quality of care psychiatrists provide to patients. In fact, in my opinion, making the MOC with PIP program a mandatory requirement for admission to the MOC cognitive examination may make it less likely that meaningful changes will occur in a psychiatrist’s every day clinical practice. Specifically, the PIP units are onerous and may not provide meaningful data about whether continuous improvement at the clinician level is actually occurring.

The reason might be that, as Dr. Oldham and the ABPN point out, neither the ABPN nor the ABMS require clear evidence from the Performance in Practice (PIP) units including Peer and Patient Feedback forms that one’s practice has changed based on the feedback provided. In terms of collecting information that might be the subject of an audit pursuant to decisions regarding clearance of diplomates to sit for MOC examinations, the ABPN just wants to know that the psychiatrist is collecting information from feedback forms, not necessarily that anything is being done to change one’s practice.

Let’s be clear: we all want to improve our clinical practice. It’s just that it’s logistically impossible to collect the kind of data with enough specific detail that would allow the ABPN or the ABMS to determine whether improvement is actually occurring. That would require patient specific information that is confidential and which psychiatrists cannot supply because of laws governing confidential health information.

Moreover, if psychiatrists are going to collect patient feedback data, how likely is it that they’re going to collect feedback from any patients who might give negative feedback? There are plenty of reasons why patients with certain psychiatric disorders might give feedback that would be critical, even highly critical, of the treating psychiatrist. Psychiatrists regularly have to file for involuntary hospitalizations for protection of patients who are dangerous to themselves and others according to state codes governing mental health and substance abuse commitments. Patients are unlikely to give positive feedback when they are committed to locked psychiatric wards. As another example, psychotic patients who are suspicious of mental health treatment and the professionals who attempt to provide it would also be critical.

It isn’t the negative feedback that is the issue. The issue is the low likelihood that psychiatrists will seek this kind of feedback in the first place. Even if it is sought, and the feedback is negative, neither the ABPN nor the ABMS insist that the psychiatrist respond to it in any way. They just want to know whether the psychiatrist is collecting this information–which I would call wasteful busy work.

Evidence for change might be discoverable in the PIP clinical unit in which physicians are required to monitor their clinical practice and develop action plans based on comparison of their current patient care practice to the medical literature in terms of well-established clinical practice guidelines as developed from the research base.

However, even with the PIP clinical units, it’s not clear that physicians have to complete all components to receive credit for completion. Specifically if the psychiatrist believes he/she is already practicing well within evidence-based clinical practice guidelines, the improvement portion of the exercise may not be required.

Then there’s the issue of how psychiatrists involved primarily or completely involved in research or administration will meet the MOC PIP requirements. There’s a whole category of psychiatrists who don’t see patients. Are they to be exempt from being board certified? Is certification even relevant for them?

We’re dedicated to support patients and one another–and we’re also very busy. There might be an incentive to cut corners by giving less meaningful attention to activities such as the MOC which can be fulfilled by simply saying “yes” to questions about whether or not PIP feedback forms have been collected.

As the MOC is currently structured, based on the honor system, and based on the incentive of being allowed to sit for the MOC cognitive examination or not based on ability to show one is merely collecting clinical and feedback information, I would expect psychiatrists to obey the letter of the law. I wonder if we could stop this train and try something different to show the public that psychiatrists are truly committed to continuous improvement.

I wonder if we could show the public that we are devoted to the spirit of the law as well. Is there any compelling reason to make the MOC PIP units required prerequisites to sitting for the MOC cognitive examination? Since there’s no way to prove that they document genuine improvement in clinical care anyway, why couldn’t we make them voluntary?

Further, why not require the ABMS to document which board-certified psychiatrists are designing their own voluntary professional self-improvement programs, either individually or as departments or private practice groups? Currently on the ABMS web site, patients can find out which psychiatrists are board certified and whether they are participating in the MOC. Could we modify it so that those psychiatrists who are designing or involved in quality improvement programs are recognized as top performers on the ABMS website?

I think that would provide a meaningful incentive and positive reinforcement for continuous improvement to many psychiatrists.

You can find other posts about the MOC on the Home Page on my blog site under the blue menu button labeled “Let’s Rap About the Maintenance of Certification.”

1. Nasrallah, H. A., MD (2011). “The model psychiatrist: 7 domains of excellence.” Current Psychiatry 10(11): 5-6.
What makes a first-class psychiatrist? What are the traits that characterize the “ideal” psychiatrist? How does a good psychiatrist become great? There are many possible answers depending on who is asked.

2. Simon, R. I., MD (2011). Improving Suicide Risk Assessment: Avoiding Common Pitfalls. Psychiatric Times, UBM Medica Publication. 28: 16-21.

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