Nigella Be With Us

Well, today is the Policy Forum for a variety of Policy Request Statements including my PRS 14-02: Support of Lifelong Learning and Opposition to Mandatory Maintenance of Certification (MOC). I’m on duty and unable to attend to give a verbal statement, but I’ve submitted my written statement. The meeting starts at 12:30 in room 5181 of the Medical Education Research Facility at the University of Iowa Carver College of Medicine.

Something tells me I’ll need something for luck because I happen to know there is dissent about PRS 14-02. I think we just got it. One of the residents got a helium-filled balloon of a giraffe recently for the consult office:

Nigella the new psychiatry consult office mascot for luck and good will.



Its name is Nigella because Nigel didn’t fit after someone noticed that it seemed to have heavy eye makeup. Nigella will need weekly trips to our hospital’s gift shop for helium booster shots. She got one today because her ego was extremely deflated, if you know what I mean. Nigella is expected to help the psychiatric consult team members remember to smile and not take ourselves and our job too seriously.

I think patting her on the neck (just anywhere along the neck) for good luck could be a new tradition for the psychiatry consult service. Mentioning the gift shop reminds me of an interesting floral arrangement I saw there yesterday:

Fire truck floral
“A consultation service is a rescue squad. At worst, consultation work is nothing more than a brief foray into the territory of another service…the actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home… (However), a liaison service requires manpower, money, and motivation. Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned to him.”—Dr. Thomas Hackett.


The psychiatry consult service is a lot like a fire brigade putting out fires all over the hospital. I almost bought the fire truck as a sort of prize that could be given to any resident to hold for the month in recognition of dealing skillfully with a very tough consultation issue, delivering excellent patient care, or presenting a thoughtful and well-put together CPCP that changes our practice. But I couldn’t figure out how to defray the cost of getting a new bouquet of flowers for it every month. Also it cost $40. I’m pretty cheap.

Speaking of putting out fires, I often get the sense that some of the articles I read about MOC sound like advertisements for the American Board of Medical Specialties (ABMS). Those of us who support the principle of lifelong learning but oppose MOC may often get the impulse to put out every smoldering brand that supporters of MOC toss out. Writing the responses means getting past the moats and crenelated battlements of the editorial departments of the journals in which they appear. I’m a pretty busy doctor and I just don’t have time to do that.  However, the most recent article was pretty blatantly an advertisement and it was in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) [1].

Gorrindo and Stock say a few things about the MOC “research” that are probably overstated and at least debatable:

Although complex, at the end of the day, the MOC process provides reassurance to patients and health care institutions regarding physician competence. However, there are few data to assess the impact of MOC on clinical care. Small studies outside of psychiatry have correlated MOC activities with positive outcomes. Learning through self-assessment modules has been correlated with performance on MOC cognitive examinations in critical care medicine. Practice improvement modules that are disease specific, such as diabetes, asthma, and preventive cardiology, have been favorably received by practitioners, indicating the feedback helped guide and improve care.

I guess they haven’t heard about the retrospective pilot study which “investigated the ability to demonstrate an effect on 2  specific MOC modules for family physicians—the Self-Assessment Module (SAM) from Part II MOC and the Performance in Practice Module (PPM) from Part IV MOC—on the quality of care delivered by family physicians to their patients. The study focused on study physicians’ patients with an established diagnosis of type 2 diabetes mellitus.” The study assessed the feasibility of obtaining and using electronic health record data to investigate questions about MOC as a quality improvement process [2].

While it shows that the question of the usefulness (or not) of MOC can be studied, the method probably cannot be applied to measuring whether or not the quality of psychiatric treatment can be improved by participating in MOC. I ran this study by a colleague in my department and he doubted that that it could be applied to assess the use of MOC processes in the treatment of psychiatric illness. I also caught a child psychiatrist in the hallway to ask her thoughts about MOC–she’s not a fan of it and really doesn’t understand much of the debate pro and con. She’s pretty busy, like the rest of us and doesn’t see how the expensive and time-consuming products that the boards demand we purchase in order to qualify to sit for the recertification exam actually improve patient care.

The study has a number of limitations, which the authors point out, not the least of which is that the number of participating physicians recruited was low. The results are not generalizable to other physician specialists, including psychiatrists. And while the study seemed to support the potential for MOC to contribute to improving quality of medical care by family physicians, the authors point out “The results support the concept that participation in MOC activities is associated with improvements of care, although the ability to track impact based on the particular MOC activities seems limited, at least in clinical areas with significant overlap of measurements.”

In fact, this study seems to validate the major concern physicians have about specific MOC processes, especially the Performance in Practice modules.

Gorrindo and Stock go on to remind us that “Physicians board-certified in child psychiatry are not mandated to maintain their adult psychiatry board certification, unlike all other psychiatric subspecialties.” I think this is meant to persuade us that this is some kind of sweet deal proving that the ABMS loves us.

If you’re a hard-working doctor who doesn’t let anyone pull the wool over your eyes and you’re tired of being pushed around, you’ll pat Nigella’s neck (at least in spirit) for luck and hope that PRS 14-02 is adopted today. Nigella be with us.


1. Gorrindo, T. and S. L. Stock (2014). “Bringing Education to the Bedside: A Primer on Continuing Medical Education (CME) and Maintenance of Certification (MOC) Requirements.” J Am Acad Child Adolesc Psychiatry 53(10): 1042-1044.
2. Galliher, J. M., B. K. Manning, et al. (2014). “Do Professional Development Programs for Maintenance of Certification (MOC) Affect Quality of Patient Care?” The Journal of the American Board of Family Medicine 27(1): 19-25.
Objective: The objective of this study was to examine the relationship between physicians’ completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered.Methods: Physicians from the Electronic National Quality Improvement and Research Network (eNQUIRENet) were enrolled. Data from their electronic health records were compared before and after they completed one or more MOC modules for family physicians (Self-Assessment Module [Part II MOC] and Performance in Practice Module [Part IV MOC]; SAM/PPM). Process data and other quantitative clinical measures for all adult patients with a diagnosis of type 2 diabetes were gathered from each study physician. General linear mixed effects models were used to analyze data before and after the MOC modules, adjusting for clustering of patients within physicians.Results: Physicians participating in SAM/PPM activities demonstrated greater improvements over time in 11 of 24 measures in process and intermediate outcome measures related to type 2 diabetes care compared with non-SAM/PPM participants. All groups demonstrated improvements over time.Conclusion: Participation in SAM/PPM activities is associated with greater improvements in care, but the association between activity undertaken and specific improvements is difficult to demonstrate.