MOC and the FOCUS Journal for Psychiatry: Yesterday and Today

So have you heard the latest about the American Psychiatric Association (APA) and the American Board of Psychiatry and Neurology (ABPN) and their collaboration (or collusion depending on your perspective) regarding the newest wrinkle in the collection of CME activity transcripts for Maintenance of Certification (MOC)?

This is a complicated story so bear with me. I subscribe to one of the ABPN approved MOC products, called the FOCUS Journal of Lifelong Learning in Psychiatry. This week I discovered I couldn’t access any of the self-assessment quizzes on line, which is how I usually obtain my CME, Self-Assessment, and Performance in Practice (PIP) credit.

Admittedly, I had received a couple of messages last month about a change that was going to occur in the program–when I was so busy on the general hospital psychiatry consultation service that I didn’t even have time to read them thoroughly. I would quickly scan them and get the idea that they were mostly advertisements from APA. They both said the same thing:

Dear American Psychiatric Publishing CME Participant,

We are pleased to announce that we are upgrading PsychiatryOnline.org and redesigning the delivery of our online CME products – including our Study Guide CME (previously called Self-Assessment CME), The American Journal of Psychiatry CME, and FOCUS: The Journal of Lifelong Learning CME.

We are creating a focused, simplified, and enriched experience that will include all educational opportunities from the American Psychiatric Association. Our move to a unified online education portal allows for exciting new features, an improved user experience, and incredible new offerings in the years to come.

Please complete any CME activity that you have in progress and claim credits by Monday, October 27, 2014. All of your CME history will be available on the new website but any CME activity that you have finished in the month in October 2014 will not be available in the new system until mid November 2014.

Many of the CME activities associated with your 2012 subscription to FOCUS will be expiring soon.

Fall 2012: Depression and Dysthymia—Expires December 31, 2014

Summer 2012: Child and Adolescent Psychiatry: Life Cycle and Family—Expires December 31, 2014

Spring 2012: Schizophrenia—Expires December 31, 2014

Winter 2012: Women’s Mental Health—Expires January 01, 2015

Self-Assessment Exam—Expires October 31, 2015

Thank you for your patience while we move to our new home!

If you have any questions, please contact our Customer Service department at 1-800-368-5777 or 703-907-7322.

So it turns out there’s a lot more to this message than meets the eye. And for the psychiatrists who use the FOCUS journal, the key part of the message is the customer service phone number, 1-800-368-5777 or 703-907-7322

If I hadn’t called customer service, I would not have learned how to regain access to the online FOCUS journal. The customer service representative I talked to was also very helpful answering my question about the potential for redundancy in this system of recording CME activities in both FOCUS and ABPN systems pursuant to keeping up with MOC record-keeping requirements.

According to customer service, there’s going to be direct electronic uploading of CME activities transcripts from APA FOCUS to ABPN Physician Folios. But hang on; the only way I could verify this was to get representatives from both ABPN and APA in the room together (so to speak) by sending email messages to the support representatives from both organizations. Remember, only the APA customer service representative clued me in on this, not anyone in the APA education committee nor anyone at ABPN. I told the customer service representative that they must be getting a lot of calls.

Boy, was that an understatement. The ABPN representative didn’t even mention it at first and I got the impression she was not even aware of it.

The initial message from APA was as follows (POL stands for PsychiatryOnline, where FOCUS used to live):

“Focus credits have been moved from Psychiatry Online to the APA Learning Management System at www.apaeducation.org.  While these credits will be transferred to ABPN on behalf of APA members, it doesn’t happen instantaneously—we send a report to ABPN once a month, so you won’t see the credits appear on your ABPN Folio right away.  Additionally, because of the content migration from POL to www.apaeducation.org, any activities completed on POL in September or October of 2014 are still being reported to ABPN.  If you’re an APA member and your ABPN Folio is not up to date by December 1, please let me know and we’ll investigate.  In the meantime, I apologize for the inconvenience—it is temporary and should ultimately lead to a more straightforward system.”

“Inconvenience” is an understatement. APA could have taken a lot of pressure off their poor customer service representatives by engaging APA members in a little upfront communication about this.

The initial message from ABPN was:

“You are not required to enter CME credits into both systems.

Entering your CME credits into your ABPN folio is totally voluntary. You are not required enter your CMEs into your folio. No one except you will ever see this information.

You are required to attest in your folio account to the total number of CME, SA-CME credits on a yearly basis and to attest to having compiled the PIP requirement once every three year cycle.

This is a process of entering a number and clicking an attest button in your folio.

Please let me know if you additional question.”

Bear in mind that didn’t answer my question and it was not until I contacted both ABPN and APA representatives in the same email inquiry that ABPN admitted that the CME activity would be automatically uploaded to the ABPN Physician Folio. What was so hard about that?

Now the kicker is, unless you’re forking over almost $1000 for the annual APA membership fee and the extra $368 for a one year subscription to FOCUS (well over $600 for a two year subscription) your CME data doesn’t get uploaded to the ABPN Physician Folio.

Sound like a monopoly? Feel like you’re getting hustled? Suspect this is another racket among the many out there, including the MOC itself?

Sure, you don’t have to enter anything into the Folio–but if you don’t and ABPN audits you before your MOC cognitive exam, you’d better have paper copies of your CME credits in order to sit for the exam. For those of you transitioned to C-MOC after you’ve passed your most recent exam, you’ll start paying an annual registration fee.

So to recap:

  • FOCUS Journal for Psychiatry subscribers need to move their access link to apaeducation.org and log in with their previous PsychiatryOnline usernames and passwords.
  • You can access CME activities including quizzes at the new link and record credit, which gets uploaded to your ABPN Folio only if you’re an APA member and only if you already have an ABPN Folio and even then only once a month or so—maybe (we’ll see).
  • You don’t have to record anything online but you should keep paper copies of your credits in case of an audit before your 10 year MOC cognitive exam.
  • The only real reason to do this is if you’re required to keep up with MOC. Those who are grandfathered don’t have to bother with it—for now.

I have this urge to say something like “The preceding has been a public service announcement…” but isn’t that a job for the APA and the ABPN?

As many of my readers know, I’ve been considering not renewing my APA and AMA membership, which the above makes a little more difficult to do with the former and the following tweet a bit harder to do with the latter:

Note the following bullet points in the AMA policy statement:

  • The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.
  • Actively practicing physicians should be well-represented on specialty boards developing MOC.
  • MOC activities and measurement should be relevant to clinical practice.
  • The MOC process should not be cost-prohibitive or present barriers to patient care.

Now go to the recent Focus (not related to the FOCUS in this post) Group study recently published in JAMA Internal Medicine and which didn’t have much of anything good to say about MOC despite the bias in favor of it by at least one of the authors (Holmboe) [1]. If you have a username and password for Medscape (hey, registration is free), you can view the article with over 100 comments about it at

You know, the AMA policy sounds a lot like what opponents of MOC and Maintenance of Licensure (MOL) including me have been saying for years. Can the AMA back it up–like they backed up the Affordable Care Act imposition of the PQRS MOC program (get ready for penalties from CMS in 2015 if you’re not entering data for this!)?

The Iowa Medical Society accepted my Policy Request Statement to support the principle of lifelong learning and oppose mandatory MOC for licensure, hospital privileges and reimbursement from third party payers in September and adopted my resolution to oppose MOL last spring.

All this circus shows is what most physicians already know: that MOC and MOL are incredibly complicated and expensive time burdens for physicians and are so far not identified in the evidence-base as conducive to improving patient outcomes or the physician-patient relationship, despite the commenter’s claim below the new AMA policy. There is currently nothing “voluntary” about MOC at all; ask any real doctor who has to participate in order to retain hospital privileges or secure reimbursement from third-party payers.

And what would help us provide safe and effective medical and mental health care is allowing us to find our own ways to incorporate a culture of excellence and practical innovations into our practices instead of tossing out the mostly irrelevant and costly MOC products geared to promoting competency being sold by organizations which have a clear conflict of interest in this process.

The President and CEO of the ABPN, Dr. Larry Faulkner, said that “MOC is not going away…” at the October meeting of the American Academy of Psychiatry and the Law. That’s probably true. We’re never returning to the yesteryear of lifetime certification and CME only. Remember, CME requirements used to provoke just as much angst as MOC does now and, ironically, it’s what many doctors today insist is the best standard to which we should be held.

But I can see why some of us long for the past.

 

Reference:

1. Cook, D. A., et al. (2014). “Getting maintenance of certification to work: A grounded theory study of physicians’ perceptions.” JAMA Internal Medicine.
Importance  Despite general support for the goals of maintenance of certification (MOC), concerns have been raised about its effectiveness, relevance, and value.Objective  To identify barriers and enabling features associated with MOC and how MOC can be changed to better accomplish its intended purposes.Design, Setting, and Participants  Grounded theory focus group study of 50 board-certified primary care and subspecialist internal medicine and family medicine physicians in an academic medical center and outlying community sites.Exposures  Eleven focus groups.Main Outcomes and Measures  Constant comparative method to analyze transcripts and identify themes related to MOC perceptions and purposes and to construct a model to guide improvement.Results  Participants identified misalignments between the espoused purposes of MOC (eg, to promote high-quality care, commitment to the profession, lifelong learning, and the science of quality improvement) and MOC as currently implemented. At present, MOC is perceived by physicians as an inefficient and logistically difficult activity for learning or assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society. To resolve these misalignments, we propose a model that invites increased support from organizations, effectiveness and relevance of learning activities, value to physicians, integration with clinical practice, and coherence across MOC tasks.Conclusions and Relevance  Physicians view MOC as an unnecessarily complex process that is misaligned with its purposes. Acknowledging and correcting these misalignments will help MOC meet physicians’ needs and improve patient care.

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Comments

  1. Jim,

    Great work as always. You know my opinion on MOC and anybody who witnessed MOC being forced on physicians with no evidence that it beats lifelong learning or CME as usual agrees.

    Conflict of interest always seem to apply to anyone except those who are trying to disempower or profit from physicians.

    Liked by 1 person

  2. Thanks, Paul. I got the idea for including the AMA policy from you. By the way, this post is very similar to a message I sent my department along with a challenge to discuss why we still require MOC participation.

    I got one reply so far, “you are simply the best; thanks.”

    Well I appreciate that but if we could work as a group… Who loves you, baby?

    Like

  3. I hope you have seen this and are planning to report!

    Worth a blurb to all concerned-the activism at the state level is causing even the AMA to come around. With 15 states already pushing for reform with several national societies as well!
    Particularly revealing is this statement from the AMA opposing the regulatory capture of medicine:
    The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.

    See:http://www.ama-assn.org/ama/pub/ama-wire/ama-wire/post/ama-adopts-principles-maintenance-of-certification?utm_source=191323&utm_medium=Lyris&utm_term=111114&utm_content=I14Recap&utm_campaign=3486706
    AMA Wire®: AMA adopts principles for maintenance of certification:

    The MOC principles will now include:
    MOC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.
    The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.
    MOC should be used as a tool for continuous improvement.
    The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.
    Actively practicing physicians should be well-represented on specialty boards developing MOC.
    MOC activities and measurement should be relevant to clinical practice.
    The MOC process should not be cost-prohibitive or present barriers to patient care.

    Liked by 1 person

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