Lifelong Learning: Making Sure Ideas Live

I’ve been eagerly awaiting the results of Psych Practice Blogger’s survey on the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) and they’re finally in.

That survey is now closed and I decided to close my survey on the National Board of Physicians and Surgeons (NBPAS), the alternative board which doesn’t require MOC participation or a recertification exam. The results are similar and respondents hail from across the country.

NBPAS Survey Results April 25 2015


Like Psych Practice Blogger, I wonder where we go from here. That’s pretty much been the question ever since physicians sort of woke up and realized that the MOC process doesn’t embody the principle of lifelong learning.

The other news I’ve been waiting for, although with less excitement because I think I already know it, is what the American Board of Medical Specialties (ABMS) President and CEO, Dr. Lois Nora, MD, JD, MBA announced about MOC at the American Academy of Neurology (AAN) annual meeting in Washington D.C. on April 21, 2015. As I’m sure many doctors did, I got the form letter from her about my feedback on the MOC on April 15:

Dr. Lois Nora Thank You Form LetterSo far I haven’t seen anything online about what she said or what the AAN membership thought about it, but I did see all of the YouTube video of the Presidential Plenary Address of the current President of AAN, Dr. Tim Pedley, MD, FAAN at the 2015 annual meeting. While the portion of his lecture about the MOC begins about 26 min 50 sec into the video and stops at roughly 34 min 10 sec, I suggest viewing the entire 35 minute lecture. It gives me a sense of a larger perspective on the condition of American medicine in today’s political and economic environment. It runs all of about 7 minutes. While I believe it’s important to see where MOC as an issue for front-line doctors stands in the total scheme of things, I wonder of Dr. Pedley (who I suspect has a lifetime certificate) and Dr. Nora (who was trained as a neurologist, by the way) really understand what the MOC is like for the average non-executive doctor. And I didn’t hear Dr. Pedley mention systems pressures over which we’re not allowed any control (including regulatory pressures) as an important contributor to physician burnout.

I suspect the remarks of Drs. Pedley and Nora were very similar even though I don’t have the comments of Dr. Nora for comparison. And I believe the American Psychiatric Association (APA) message about MOC (and it will again likely mirror that of Dr. Nora) will be a repetition of this one at the annual meeting in Toronto in May. This is despite the recent mention of opposition to Part IV of MOC in the April 17, 2015 issue of Psychiatric News, Vol. 50, issue 8.

“Maintenance of Certification (MOC): Trustees, acting on the recommendation of the Assembly Executive Committee, voted to support the elimination of Part 4 of the MOC requirements and to recommend to the American Board of Psychiatry and Neurology that it advocate to the American Board of Medical Specialties (ABMS) for the elimination of Part 4 of MOC (see page 16). The ABMS oversees certification and MOC for all medical specialties.”

And there’s Dr. Pedley’s article in a fragment (I don’t have the full issue because I’m not a member) of the April issue of AAN News about MOC. The full letter is here. It was originally published online in February. Then look at the remainder of that fragment of AAN News, which carries a portion of an article in the President’s Column by Dr. Pedley entitled “Ave et Vale [Hail and Farewell…translation inserted by the blogger]: One President’s Term Ends and Another’s Begins.”

There is definitely a conflict here. That’s how it seems to be–us vs them. This was also brought home to me when I saw the Wikipedia article about MOC. It’s a recent addition and there’s a warning at the head of it indicating that the “the neutrality of this article is disputed.” If you navigate to the dispute itself it’s very clear who dominates control of what is clearly a passionately adversarial debate. It’s the ABMS.

Can there be neutrality on this issue? Look at the Wikipedia articles on Bigfoot and UFOs and you might wonder why there couldn’t be. Those articles are not marked by warnings about a lack of neutrality, yet no one would dispute their controversial nature. On the other hand, what would be gained by attempting to wage this war on Wikipedia?

I see it as another one of many markers of how unhappy physicians are about MOC, so much so that you get the sense we’re flailing in any possible venue, desperate to be heard yet finding no one really listening.

Psych Practice Blogger asks where do we go from here, from the individual perspective of the rank and file doctor in America when it comes to participation–or not–in the MOC in its current form. There is a sadness inherent in our position. A couple of years ago a colleague said this struggle would never go anywhere. Now few would argue that those of us who uphold the principle of lifelong learning and oppose MOC as a vehicle for implementing it are making a substantial impact on this debate.

So let me try to answer the question, “What would you do with this?”

As an individual psychiatrist, I need to get a clear understanding of what opposition to MOC would mean in my context. I get mixed messages about what board certification means at my hospital and I suspect there are political and financial reasons for that. I will hedge my bets about joining NBPAS even though deep in my soul I agree with the leaders of that alternative certification process. My context also includes where I am in the course of my career. I’m nearing retirement and I need to be realistic about what noncompliance with MOC would mean at a time when I need to ensure that my wife and I will have a reasonably secure retirement. I can’t afford to lose hospital privileges now if my employer decides that board certification in fact is a metric which is crucial to meet in order to keep them. The answer for me will not work for everyone.

When I think about it, I’m sad too. And I think about it a lot. I’ve been at this a good while. But I keep hoping the idea that a systematic program of lifelong learning as a principle is worthwhile as long as the implementation is practical and just will be recognized and honored. We need to keep trying to work it out. And for that you need more than individual effort. I remember even when my own department leaders were reluctant to discuss the issue openly a couple of years ago. Now they’re more receptive to the idea that those who oppose MOC are not opposed to smart, productive, and honest professional development. I hope we don’t let ideas like this die.

2 thoughts on “Lifelong Learning: Making Sure Ideas Live

  1. I couldn’t agree more, George. The first year Neurology residents are starting to use the Psychiatry Consultation service as a major rotation and they seem to know little or nothing about the MOC issue before I tell them about it.

    I think it will be easier to get their attention now that the AAN has emerged actively addressing this as a controversy which needs to be resolved not just to the satisfaction of patients (who probably don’t know as much about it as the boards would have us believe) but to physicians as well.


  2. Jim,

    I think the good news in all of this is that MOC is clearly a political battle. It has nothing to do with scientific evidence. We all know how politics works. The people in power (ABPN, ABMS) will do everything they can to keep it. That includes making things as painful as possible for those in opposition. That is how physicians have been pushed around for years. One of the best things they can do to maintain their power is to get a lock on credentialing and state licensure. The opposition needs to be doing the same thing. If I were advising people I would look for this to be a state-to-state battle at the level of the Attorney General’s Office. Activist Attorney Generals are the best way to effect health care law change within states and they are generally also interested in anti-trust issues. I can’t think of a bigger anti-trust issue than a non government entity trying to be the exclusive provider of a service.

    In this case it comes down to a choice, continued pain and suffering in a profession with very high burnout rates or taking a modest step to improve our lot. I think for the first time there is also a glimmer of hope with a real alternative to the hegemony of the Boards.

    The real battle has to occur at the level of the young physicians. There is a lot of political hype and outright ageism being used at that level. They are being encouraged to see themselves as a new business and collaborative care friendly generation of physicians unlike the dinosaurs they are replacing. Some of these younger docs write like managed care executives from the 1990s. They have the numbers and the power. The question is whether or not they have the political savvy to break this monopoly or not and in the process drastically improve their future lifestyle.


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