The MOC, A Path to Reflection and Improvement…or Just a Hound Dog?

Maintenance of certification in Internal Medicine: participation rates and patient outcomes | Buscemi | Journal of Community Hospital Internal Medicine Perspectives

I was alerted to this most recent review of the Maintenance of Certification (MOC) process (see link above) for the American Board of Internal Medicine (ABIM). The upshot is that the process is onerous and doesn’t ensure physicians are up to date. The same could be said for the MOC for psychiatrists and the American Board of Psychiatry and Neurology (ABPN) would do well to consider the parallel.

Currently, I’ve been co-staffing our Medical-Psychiatry Unit (MPU) for over 16 years. The ABPN doesn’t know what I do to improve my ability to provide patient care nor will I ever be able to convey to the board how I engage in continuous improvement. The MOC is like a hound dog, purporting to be a high-class way of ensuring the ability of doctors to provide high-quality care, but all it really manages to do is get in the way, snooping around my door. While the recommendation to physicians is to engage regularly in reflection about our practice in order to find our flaws in our approach to clinical care, examine the research evidence supporting different and more effective processes, the MOC doesn’t provide a method to convey how to reflect or how to demonstrate that they are, in fact, reflecting.

I think it’s ironic that the way I reflect about my practice on the MPU will never be known except to those who bill for my services based on my clinical documentation in the medical record–and it’s anybody’s guess how often the hospital gets paid for that. You heard right. We may or may not get paid (I get mixed messages from billing about it), simply because the U.S. payor system doesn’t recognize complexity in medical, psychiatric, social, and health care system delivery models and policies. Most payors cover a single problem per provider per day based on the most important clinical problem– which is the medical issue, according to the insurer’s rules. The MPU is a medical unit primarily, administered by the department of internal medicine. So in the co-attending model, the psychiatrist functions as a consultant who is required to write progress notes on every patient, but in fact is more like a volunteer in the sense that bills are submitted for psychiatric services which frequently are not paid.

It’s a lot of work to create progress notes documenting what I think are the main psychiatric issues which might interfere with treating their medical problems, or what medical problems or medications might be causing the psychiatric problems or vice versa. The internist can simply co-sign the resident physician’s note, but because the MPU is administered by internal medicine, my name as the psychiatrist can’t even appear as a co-attending. The billing department employees have made it very clear they don’t want my name on any internal medicine note that will be submitted for billing.  In a real sense, the general psychiatrist on the MPU is invisible.

So I write all my own notes, which are submitted by psychiatric billers but often go unpaid (ADDENDUM: recently I discovered that while some of them might be paid, psychiatry doesn’t even bill when I’m not co-attending). So much for integrated care on an administrative level. What does that have to do with the MOC? I’ve learned to use my notes as my way of reflecting on the care of my patients, and they are my patients by the way, even though I’m supposed to be invisible from a medical billing standpoint. My daily notes, painstakingly created and often consuming at least 2 hours a day, despite my use of voice recognition software, (which makes horrendous errors if my vigilance lapses) make up my journal, as it were. I document my medical literature searches, my thought process, my conversations with family, surrogate decision makers, the diagnostic judgment calls, the “truing measures” I use to help me, by “successive approximations” arrive at the most comprehensive diagnostic and integrative formulation, and the safest, most effective treatments acceptable to patients which Frankel, Bourgeois, and Erdberg describe in their book, “Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model” [1].

Who reads my journal? No one at the ABPN or the American Board of Medical Specialties (ABMS) or the Federation of State Medical Boards (FSMB), because it contains confidential, protected patient health information. In fact, I don’t think my internal medicine co-attending or even the residents read it. None of us have enough time to read each others’ notes, although we collaborate on rounds, getting the integration job done right on a clinical level. But my journal is the way I reflect on my clinical care and I’m constantly working on how to improve it. The MOC as it is currently designed promotes reflection but doesn’t facilitate it. In fact, the MOC discourages this kind of reflection. It encourages reliance on treatment algorithms, which are useful to the extent they provoke us to question them when they invariably prove to be an inexact fit in the real world in which health care providers, patients, families, and policy makers live. The MOC makes me point and click on buttons documenting the completion of Performance in Practice (PIP) modules. But the only one who really knows about my struggle to keep up with the medical literature, to meet the needs of my patients, to find the best path through health care system complexity is me.

The MOC should be about helping doctors provide the highest quality patient care possible. It fails miserably. I can do better by daily reflection in my daily progress notes in which I document the struggle, the thinking through the ways to work around our fragmented health care system’s bewildering maze of obstacles to providing health care at all, much less the best care. I’m aware that it’s really my journal because it isn’t used by anyone else. But it’s better than the MOC.

1. Frankel, S. A., J. A. Bourgeois, et al. (2013). Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model. New York, Cambridge University Press. URL : http://www.barnesandnoble.com/w/comprehensive-care-for-complex-patients-steven-a-frankel/1111389980.

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