Remember that letter of apology from Dr. Richard Baron, MD, President and CEO of the American Board of Internal Medicine (ABIM) to diplomates, admitting that the ABIM got it wrong about that awful Maintenance of Certification (MOC) program? Well, it must have caused quite a stir at other specialty certification boards because here’s the letter from Dr. Larry Faulkner, MD, President and CEO of the American Board of Psychiatry and Neurology (ABPN) I received, commenting about that–there were no apologies:
The purpose of this letter is to respond to inquiries from many American Board of Psychiatry and Neurology (ABPN) diplomates concerning the recent communication from the American Board of Internal Medicine (ABIM) about changes it plans to make in its Maintenance of Certification (MOC) Program. The ABIM has now pledged to engage the internal medicine community in an effort to make its MOC Program more relevant and meaningful for physicians involved in patient care and clinical leadership. While all 24 Member Boards of the American Board of Medical Specialties (ABMS) have agreed to follow its MOC Standards, the specific manner in which those standards are met is largely up to the Member Boards. It is gratifying to note that most of the changes now planned by the ABIM are consistent with policies and practices already in place in the ABPN MOC Program.
At the heart of the ABPN MOC Program are several core beliefs that serve as the foundation for our specific requirements.
- The ABPN believes that the vast majority of its diplomates already pursue life-long learning. The main tasks for the ABPN MOC Program are to support the ongoing professional development of our diplomates and to reinforce and document their life-long learning efforts in a manner consistent with the expectations of outside organizations and the public.
- The ABPN believes in a collaborative approach to MOC. We work very closely with our related professional societies like the American Psychiatric Association, the American Academy of Neurology, and virtually every subspecialty society. We encourage those societies to develop relevant MOC products for their members and we have a streamlined process in place for the review and approval of those products. We also recommend that societies provide those MOC products to their members for free or at reduced cost, and many societies have recently followed our recommendations.
- The ABPN believes that it must avoid any potential conflict of interest in its MOC Program. We develop no MOC products other than the MOC examinations, and we depend upon our professional societies for the development of MOC products for self-assessment, CME, and performance improvement.
- The ABPN believes that its MOC requirements must not place an onerous burden on diplomates. As a result of recent feedback from diplomates, we significantly reduced the self-assessment and performance improvement requirements for diplomates in our 10-Year MOC Program. We also recently made a decision to give 3 years of MOC credit to diplomates who have completed accredited subspecialty training and passed our subspecialty certification examinations.
- The ABPN believes that it is crucial to allow diplomates to select the specific MOC products that best fit their needs for self-assessment, CME, and performance improvement. We have never required that diplomates complete specific MOC activities that are not relevant to their own practices. With the flexibility afforded in the new 2015 ABMS MOC Standards, we recently expanded the range of options available for diplomates to meet its self-assessment and feedback requirements.
- The ABPN believes that it is important to recognize and give diplomates MOC credit for what they do already. We know that many diplomates work in organizations requiring quality improvement and feedback activities that are very similar to our MOC requirements, and we want to recognize those diplomate activities.
- The ABPN believes that the vast majority of diplomates should be able to pass its MOC examinations. All of our MOC examinations are clinically relevant and have reasonable passing standards. To date more than 95% of diplomates have passed our MOC examinations, and diplomates are given two chances to pass an MOC examination before their certification is rescinded.
- The ABPN believes that it must only report whether or not diplomates have met its MOC requirements. While we encourage diplomates with “life-time” certificates to participate in MOC, we also maintain our covenant with them by being clear that they are not required to do so. We also recently modified our requirements to make it easier for our “life-time” diplomates to enter our Continuous MOC Program should they choose to do so.
- The ABPN believes that diplomate attestation and random audit are acceptable methods to document their performance in MOC. We never require diplomates to submit any MOC or practice data to the ABPN.
- The ABPN believes that its MOC fees must be reasonable. We carefully review MOC fees annually. Fees in our 10-Year MOC Program were reduced 25% in 2008, another 6% in 2009, and will be reduced another 7% in 2016. All total, MOC fees will have been reduced 34% since 2007 and are at a level significantly below the average for all Member Boards.
While the ABPN recognizes that its MOC Program is continuously evolving, we are planning no other changes in our MOC requirements at this time. The ABPN is continually looking for more ways to improve its relevance and flexibility and to reduce the burden it places on our busy diplomates. As we have done in the past, we welcome any constructive recommendations in that regard. Our sincere hope is that the ABPN can be seen by diplomates as an important ally that can help them to document their life-long learning for their patients and those organizations who license, credential, and pay for their services. We commit to doing all we can to make that hope a reality.
Larry R. Faulkner, M.D.
President and CEO
And here’s my reply:
Dear Dr. Faulkner,
While I appreciate your message, I would like to point out that the ABPN PIP products are, in general, not relevant to my practice and waste my time. In my opinion, I think they should be removed from the requirements for MOC. There is no high-level evidence that MOC improves patient outcomes. I’m sure you’re aware of the MOC studies published in JAMA recently, neither of which showed any significant findings supporting MOC:
Hayes, J., et al. (2014). “Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality.” JAMA 312(22): 2358-2363.
Gray, B. M., et al. (2014). “Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.” JAMA 312(22): 2348-2357.
I think what I currently do as a consulting psychiatrist for self-improvement is adequate. Just one of these activities is the weekly case conference, the Clinical Problems in Consultation Psychiatry (CPCP). The instructions:
“Clinical Problems in Consultation Psychiatry (CPCP):
A weekly case conference held Wednesdays from 8:00 a.m. to approximately 8:45 a.m. Each week, a case is selected from the Daily Review Rounds Records to illustrate a clinical problem for the next week’s meeting. The residents are assigned dates when they rotate. The medical students are welcome and even encouraged to participate as well.
This is a practical way to approach teaching the Practice-Based Learning & Improvement Core Competency. This helps develop the habit of reflecting on and analyzing one’s practice performance; locating and applying scientific evidence to the care of patients; critically appraising the medical literature; using the computer to support learning and patient care; facilitating the education of other health care professionals. This is applying principles of evidence-based medicine (EBM) to clinical practice.
- Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine
- Skills are needed to integrate the available evidence with clinical experience and patient concerns
- Application and evaluation of EBM skills will provide a frame-work for life-long learning.
Self-evaluation is vital to the successful practice of EBM:
- Am I asking answerable clinical questions?
- Am I searching the literature?
- Am I becoming more efficient in my searches?
- Am I integrating my critical appraisals into my practice?
The assigned resident is responsible for searching the literature and selecting one or two teaching papers for the conference. Presentations will begin with a review of the case, followed by a summary of the references with subsequent round table discussion.
Circulate copies of 2-4 pertinent articles to team members including psychiatric nurses and faculty. A copy machine is available in the departmental administration office. Consult staff can also assist with obtaining copies.
Presentations begin with a 5-minute summary of the case with discussion of both psychiatric and medical aspects of evaluation and management. The remaining time is spent summarizing the pertinent data in the articles. Residents and medical students are encouraged to use the case conference material as preparation for submitting a case report or letter to the editor.”
I have been actively engaged in my own lifelong learning for my entire career. I have also, as you probably know, been actively engaged in opposing MOC and Maintenance of Lifelong Learning (MOL) as they are now designed. While I have never believed that MOC adequately embodies the principle of lifelong learning, I have always believed that pursuing lifelong learning is an essential part of my role as a physician. However, as a result of what I believe to be the excesses of empty busy work inherent in MOC, I have felt compelled to pursue a course of resistance which has led to my sponsoring resolutions to oppose both MOC and MOL in Iowa. Both have been adopted by the Iowa Medical Society. And all the while, I’ve been compliant with MOC.
In my view, you can point to the excesses of ABIM and compare ABPN MOC favorably, more because of how egregiously burdensome the ABIM MOC process is rather than how successful the ABPN MOC is at promoting physician competence.
Thanks for listening,
James J. Amos, MD
I can’t change the ABPN. I’m just disappointed that we gave up excellence for a fiction of competence. We could have done better–and still might.