Update on Maintenance of Certification: Change Board Recertification Web Site

I just recently found about an organization called Change Board Recertification and you can view their web site at http://www.changeboardrecert.com/.
I found out about them only in the last month, but they’ve apparently been around since 2010. Any readers who visit my blog with regularity know about my opposition to the Maintenance of Certification (MOC) and Performance in Practice (PIP) requirements for board certification. Let’s be clear. I’m fully in support of continuing education and continuous improvement, but there’s no evidence that the MOC/MOL serves the purpose major regularity bodies claim for it.

It would be easy to assume that the rank and file of physicians, including psychiatrists, agree with the MOC and the idea that the next step, Maintenance of Licensure (MOL, which I’ve also posted about) naturally follows. Just visit the American Board of Medical Specialties (ABMS) web site, Welcome to ABMS: Improving healthcare quality through board certification. The language and testimonials create the impression that everyone is on board with MOC/MOL. Nothing could be further from the truth, as you can see from a cursory examination of the Change Board Recertification site or speaking to fellow physicians. Further, I think it’s important for physicians and patients as well as health care policy makers to know about the organized dissent on the issue and the proposed alternatives to it as well, which you can read at the Association of American Physicians and Surgeons’ website:  Change Board Recertification AAPS Web Site. A recent interview with the leaders in the reform movement is worth close reading:

Doctors look for alternatives to maintenance of certification – Some fight process, while others form, join new organizations – ModernMedicine.

The alternatives outlined in the article above look credible:

Board Certification | Medical | Physician | Board Exam | Recertification ABPS

National Board of Clinical Medicine, Inc.

If large groups of physicians can create alternatives that are not only constructive but comparable choices and which are not as burdensome as the MOC/MOL, then you have to ask why is there so much momentum behind the MOC/MOL, especially when there’s no research evidence showing that it actually improves the quality of care doctors provide for patients. One reason dissenters identify is the opportunity for non-profit boards to make a great deal of money from the project.

The MOC/MOL process is inordinately complicated, far from user-friendly, and amounts to busy work. I doubt this meets the needs of patients because it draws the attention of doctors away from patient care. While physicians in internal medicine seem to take the lead on voicing dissent, many psychiatrists are not in favor of MOC/MOL either. The American Board of Psychiatry and Neurology (ABPN) describe the complicated process in the latest webinar on the ABPN web site, Webinars ABPN.

ABPN MOC Program Webinar Oct 2012

You’ll need to install the GoToMeeting codec software to view the presentation. The ABPN is following the ABMS guidelines about supporting the MOC/MOL process. Psychiatrists can indeed create a folio on the ABPN site to record and store what they collect for CME and Performance in Practice (PIP) units. But the ABPN has made it clear they don’t want actual patient or peer feedback forms. They require doctors to document them in the folio. It’s an honor system subject to audit.

The reader can view the staggering volume of letters and comments expressing opposition to the MOC on the American Board of Internal Medicine (ABIM) Chair’s website:

http://community.the-hospitalist.org/2012/08/14/on-becoming-chair-of-the-abim-why-the-board-matters-more-than-ever/#comment-142529

So this is an open letter (really an email message) I wrote to Change Board Certification in an effort to find out more about a group which purports to advocate for physicians. The answers from Change Board Recertification’s leadership are below each question:

Hi,

I found out about your web site during a discussion on LinkedIn about board recertification in an American Psychiatric Association group discussion. I’m as opposed to the MOC/PIP as anyone, as you can see from my blog posts, https://thepracticalpsychosomaticist.com/?s=MOC%2FPIP . I’ve not had a chance to look at absolutely everything on your site. I wonder if you’d be willing to share your answers to the questions below with me and my readers:

  • Who are you, including leaders, board members, and administrative support staff?
    • We’re a coalition of thousands of physicians, including the Association of American Physicians & Surgeons, http://www.aapsonline.org/, founded in 1943, active in many lawsuits, and cited repeatedly by appellate federal courts, including the U.S. Supreme Court, and also Doctors 4 Patient Care, http://docs4patientcare.org/index, a national physician advocacy group which was launched in the spring of 2009.
  • What is the action plan specifically for what you’re going to do about MOC/PIP?
    • We’ve started by educating physicians, which has been easy because so many are already justifiably outraged. Beyond that, we’ve introduced resolutions in medical societies to oppose this, contacted government officials to oppose this, and are in the process of reviewing federal regulations to see if there are provisions being violated by requiring MOC. We’ve also proposed model legislation for States to pass to curb the abusive MOC. In fact in Ohio and Oklahoma we’ve stopped the implementation of MOL.

  • Why do you ask for money donations and what do you do with the money?
    • This is being done simply to support and maintain the website. No more, no less.

  • When do you plan to introduce yourselves to and contact leaders in ABMS and other regulatory bodies such as ABPN about your proposals?
    • We already have and we can tell you about those interactions later.

  • Where is your organization based?
    • Our coalition is nationwide, and growing. 

It was also suggested that I view a couple of videos before arranging for a telephone conference:

They’re rather lengthy but serve to point out to physicians, patients, and regulatory boards that there is nothing even approaching universal agreement on what would be the best way to encourage physicians to pursue continuous improvement in their medical and psychiatric practice.

I find it ironic that the subspecialty I’m certified in which defines what I do for a living, Psychosomatic Medicine, is the one I ‘m speculating I might give up my certification in because of the MOC process. The path to getting Psychosomatic Medicine approved as a recognized subspecialty in the United States was arduous, as the past president of Academy of Psychosomatic Medicine (APM), Thomas Wise, MD describes in the paper “The journey to subspecialization…[1]. In the section The Chronology of the Journey to Subspecialization, regarding the application for subspecialty approval, which had to come from the American Psychiatric Association (APA), Dr. Wise states, “The American Psychiatric Association feared that psychiatry would become composed of subspecialties that would balkanize the general field of psychiatry, as had happened in internal medicine with its many subspecialties.” That was one of the reasons why the effort failed in 1992, although it was finally approved on the second effort in 2003, PM Subspecialty Information. This was a clear signal that APA had never been in favor of subspecialization status for Psychosomatic Medicine in the first place. I get the feeling it would not break the hearts of APA leaders if diplomates in Psychosomatic Medicine chose not to continue recertification.

There is no evidence that the APA supports a change in the MOC on any grounds, despite the overwhelming voting majority at the 2011 APA elections indicating 80% supported a referendum sharply critical of the MOC, (More on Maintenance of Certification and Performance in Practice – The Practical Psychosomaticist) actually garnering more votes than any of the candidates running for office.  Little wonder why many of us believe that the APA is not ready to support the modification or removal of the MOC process as it now stands. In fact, I think there will be a general chilling effect on the creation of new subspecialties given the complexity of keeping up with the MOC and quite possibly there will be trouble retaining doctors in almost any subspecialty as well as a notable uptick in retirement rates. Did I hear there is a growing shortage of physicians?

To be sure, the Academy of Psychosomatic Medicine (APM) is working diligently to help diplomates and diplomates-to-be manage the MOC. The APM has always offered top quality CME and self-assessment programs at their annual meetings and beyond. This year they offer a “MOC Self-Assessment Component” which can earn the attendee eight CME credits toward maintenance of certification, APM 2012 Annual Meeting.

Unquestionably though, inertia and propaganda by member boards and ABMS has persuaded many members to simply give in and comply with the MOC. However, it’s my opinion that given the complexity, waste, and cost of the program to physicians, the path of least resistance may turn out to be more difficult than active, organized and constructive resistance for everyone involved, including patients. For example, here some of my suggestions:

1. Forget about implementing a MOL because it will likely lead to duplicative requirements even more wasteful and wooly than the MOC itself.

2. Let’s ask our patients to volunteer their feedback rather than making doctors solicit the feedback. In the age of electronic health records (EHRs), why wouldn’t it be feasible, in the case of Epic (the EHR we use at our hospital) to make it easy for the patient go on line and enter their feedback anonymously via what’s called MyChart, which can route the feedback confidentially back to the doctor? That would eliminate cherry-picking and promote the provision of honest feedback the doctor could actually use for self-improvement. This would also show whether or not patients really believe that this part of the MOC process is worthwhile, which we could judge by the return rate. It makes me wish someone had actually thought to ask patients what they want before setting up this part of the MOC.

3. Do something similar to what’s listed in item 2 regarding peer feedback.

4. Survey the American people about what they think of the MOC after showing them both sides of this contested issue.

I have sent a copy of this post to the Iowa Psychiatric Society, the Iowa Board of Medicine, the American Psychiatric Association, and the Iowa Medical Society. You can read more about my opinion about the MOC/MOL on my blog site in the menu below the header, titled “Let’s Rap About Maintenance of Certification.” Let me know your thoughts.

1. Wise, T. N. (2003). “The journey to subspecialization in psychosomatic medicine (or consultation liaison psychiatry): a United States experience.” Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica 105(3): 325-330.

Advertisements

Comments

  1. And those of you who have a LinkedIn account, please consider commenting on the new discussion I started on this issue in the American Psychiatric Association Group.
    Jim Amos, MD
    The Practical Psychosomaticist

    Like

%d bloggers like this: