Regulatory Hoops!

Regulatory Hoops

Milestone Project

Maintenance of Certification and Maintenance of Licensure


Regulatory Hoops

Hoop jumpingI’ve been thinking about the different hoops of regulation that doctors have to jump through these days. They include the new Accreditation Council for Graduate Medical Education (ACGME) Milestone Project, the Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) burdens, and something that few physicians hear much about, the Ongoing Professional Practice Evaluation Policy (OPPE) and the Focused Professional Practice Evaluation Plan (FPPE).

I wonder if all of these hoops are needed. I’ll describe them in this post, which is divided into sections at the top to which the reader can page jump. The page jumping trick is sort of a metaphor for the hoops doctors have to jump through.

I’ll admit this piece was prompted by a WordPress news article about how to make long posts easier on the reader by using small pieces of HTML code for pagination and page jumping. This stuff is like Martian to a geezer like me. The instructions were difficult to follow and I think they are a wonderful example of how byzantine and poorly written rules can be frustrating rather than illuminating. It’s a lot like the regulatory capture of physicians–a series of hoops to jump through. You would not believe how many paths I had to take (hoops) just to figure out how to incorporate page jumps into this post.

Milestone Project

This section is mostly taken from my previous posts:

I had a peek at the new Accreditation Council for Graduate Medical Education (ACGME) “Milestones” program (, which is definitely complicated and reminiscent of Maintenance of Certification (MOC), and actually endorses MOC as one obviously preferred way to demonstrate a commitment to life-long learning. Have a look at page 23, under Professionalism, “Prepares for obtaining, and maintaining board certification.” And on page 27 in the Practice Based Learning module in the second footnote, “Examples include PIP module as included in the ABPN MOC process, regular and structured readings of specific evidence sources.”

That sound familiar? It should because Larry Faulkner, MD, President and CEO of ABPN (Who We Are at ABPN), is one of the members of the Advisory Group contributing to the drafting of The Psychiatry Milestone Project: A Joint Initiative of The ACGME and ABPN, as of April 2013. Don’t get me wrong; Dr. Faulkner and his staff are extremely helpful assisting ABPN diplomates navigate the wilderness of MOC, the framework for which he’s pointed out came from the American Board of Medical Specialties (ABMS).

I don’t need to tell regular readers of my blog how many physicians disagree with the regulatory board approach to life-long learning, a major criticism of which is that it takes time away from patient care.

The majority of them.

And then I read the article about the Milestone Project in residency education in the September 6, 2013 print edition of Psychiatric News, PsychiatryOnline | Psychiatric News | News Article Milestone Project. The Milestones Project is the “…latest stage of what educational leaders say is a dramatic sea change in American medical education.” It will set specific goals for assessing progress toward moving further on in their residency education toward competency. The milestones are supposedly measurable anchors for skills that might operationalize evaluation of the six basic competencies including patient care, medical knowledge, professionalism, systems-based practice, practice-based learning and improvement, and communication and interpersonal skills.

One of the examples of a milestone outlined in the article relates to psychiatric formulation. The first year resident who has attained Level 1 of this skill should be able to demonstrate that he or she can accurately summarize, report, and present to colleagues information obtained from the patient evaluation and develop a working diagnosis based on that evaluation. In Level 4, the resident should “efficiently synthesize all information into a concise but comprehensive formulation…,” which “…incorporates subtle, unusual, or conflicting findings into alternative hypotheses and formulations.”

I think we’d better make sure our faculty can still do things like this before we expect trainees to learn these skills from us. Few practitioners ever do enough formulations after graduation (if they do them at all) in academics or in private practice to make this milestone a practical measure of educational progression.

I think the Milestone Project is an extension of the Maintenance of Certification (MOC) madness rearward into residency training.

Leaders in the Accreditation Council for Graduate Medical Education (ACGME) are very enthusiastic about the Milestone Project and talk it up as though every residency program director is fully on board with it. I doubt it. Although the ACGME chair of the Psychiatry Milestone Project, Dr. Christopher Thomas, MD, says it’s not a “cookbook” for grading residents, I’m pretty sure that’s how it will come to be regarded. And program directors supposedly will not be required to use it to gauge readiness for promotion.

That makes me wonder why they’re promoting it in the first place. It’s enormously complicated, labor intensive, impractical to incorporate into the training schedule–and not required? If it’s not required and program directors will still be able to graduate trainees at their discretion, what kind of “sea change” can this innovation be expected to make?

Maintenance of Certification and Maintenance of Licensure

I’m going to reproduce my open letter to the American Psychiatric Association (APA) here:

I’m a consulting psychiatrist practicing in Iowa. I was the sponsor of the adopted resolution to support the principle of lifelong learning and to oppose Maintenance of Licensure (MOL) in my state. It was co-sponsored by the Iowa Psychiatric Society. Similar resolutions have been adopted in Wisconsin, Ohio, North Carolina, Michigan, New York, New Jersey, and most recently, Florida. The Florida Medical House of Delegates resolution also included opposition to Maintenance of Certification (MOC). They also recommended that the American Medical Association (AMA) adopt a similar resolution for national consideration.

I have always supported the principle of continuous improvement. You can see that on my blog site, The Practical Psychosomaticist. I believe that Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) interfere with my effort to deliver excellent health care.

Psychiatrists who were board certified after 1994 have to participate in ABPN’s 10-year MOC program. During each 10-year cycle, I’m responsible for demonstrating I’m keeping up to date with my medical knowledge and practice. There are 4 MOC program components for diplomates to fulfill, of which Part IV is Performance in Practice (PIP), the most controversial and labor-intensive component. It comprises three PIP units over the 10-year MOC cycle, each of which includes a clinical module and a feedback module.

These modules require me to subtract time from patient care to satisfy regulatory requirements. The ABPN requires only that I document my collection of feedback data— not that I did anything about it. There’s no high-level data showing that these activities improve patient outcomes.

In 2011, an APA referendum critical of the ABPN’s MOC PIP requirements was supported by 80% of APA voters but it failed to pass because only 25% of members cast a ballot, far fewer than the 40% needed. In 2013, an APA Caucus was organized to again discuss this as well as the recent lawsuit filed in Federal court against ABMS regarding MOC.

The FSMB proposes MOL as a framework for license renewal which “supports a physician’s commitment to lifelong learning.” Pilot projects are purportedly underway in several states to study and implement MOL. In fact, several state medical societies, a few in states participating in pilot projects, have adopted resolutions expressly opposed to MOL, again, including Iowa, Ohio, Michigan, Wisconsin, North Carolina, and New York,  New Jersey, and Florida.

The American Association of Physicians and Surgeons (AAPS) filed a lawsuit in Federal Court on April 23, 2013 against the American Board of Medical Specialties (ABMS) for “restraining trade and causing a reduction in access by patients to their physicians.”

According to David Pittman, author of the article “AMA Will Debate MOC, Guns, and the ACA” in the Medpage Today on-line article on June 13, 2013 covering the June AMA annual meeting, the AMA covered MOC proposals “…that could put the AMA at odds with the powerful American Board of Medical Specialties.” One resolution that was up for debate “would authorize the AMA to advocate against time-limited certification and oppose discrimination against physicians who are not certified in MOC programs.”


These stand for Ongoing Professional Practice Evaluation Policy (OPPE) and the Focused Professional Practice Evaluation Plan (FPPE), respectively. These are regulatory requirements of the Joint Commission to evaluate practitioner professional performance as part of the process of granting and maintaining hospital privileges. They were implemented in 2008 and many doctors probably are not aware of their existence or how important they are in maintaining professional privileges. The central administration departments of hospitals take these very seriously. Whether physicians know it or not, metrics for tracking OPPE and FPPE are being created for them. Each physician has a dossier for this data. They cover a variety of duties including timely completion of discharge summaries. I guess you find out what you’re doing wrong when you get an FPPE in the mail.

And those are probably not all of the regulatory hoops through which physicians leap. Like it or not, this is part of the price of practicing medicine nowadays. Have fun jumping through the hoops.

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