Reflections on the ABPN MOC Part IV…Again

So, I just read Psych Practice blogger’s post about the Maintenance of Certification (MOC) Performance in Practice (PIP) tool related to assessing patients for suitability as candidates for psychoanalysis.

Bravo and congratulations! It looks very professional.

It reminded me of the Delirium PIP individ Dr Jim Amos which one of the residents and I worked on just this last summer. We got preapproval for this as well and, because I too was uncertain about what “preapproval” meant at the time, I cautioned the Academy of Psychosomatic Medicine (APM) to postpone using it until after it appeared on the American Board of Psychiatry and Neurology (ABPN) website under a promised new section “…where peer-developed QI projects will be posted.” It was supposed to be “in the works” and coming soon.

That was in late August and there is still no such section visible on the website.

Now, to be fair, there are probably other reasons why the APM might not be announcing the Delirium MOC PIP Tool to members and maybe the idea about the promised ABPN section on peer-developed QI tools project was dropped. Nobody has to check with a geezer, after all.

On the other hand, since “preapproval” evidently means “approval” this could open up what the ABPN might regard as a Pandora’s Box of PIP tools. However, I doubt that will happen because of the restriction linking the tools to vetted practice guidelines.

I’m only guessing but maybe the ABPN doesn’t want to make a lot of noise about these because of their susceptibility to being gamed and otherwise criticized, as Psych Practice blogger and I have pointed out.

Which leads me to also point out the difficulty with the whole business of Part IV of the MOC program in its entirety–again:

  • Many of the MOC PIP clinical modules are not relevant to the practices of many doctors.
  • There is no reliable way to discern whether a physician is gaming the system or not and the only honest way for experienced doctors to deal with them is to indicate there was no need to change their practices because they are master clinicians already and regularly teach the content of the clinical module to trainees and junior colleagues.
  • They take time away from real patient care.
  • There is no credible high-level evidence base supporting their use.

The ABPN itself has attempted to persuade the American Board of Medical Specialties (ABMS) to make Part IV optional, ABPN Letter to Diplomates. The ABPN is still apparently committed to inflicting Part IV on its diplomates despite the clear evidence that the American Board of Internal Medicine (ABIM) believes that they can exercise a little initiative and modify their own version of the performance in practice clinical modules–not that anyone has much admiration for or trust in the ABIM these days.

Outgoing president of the American Academy of Neurology, Dr. Tim Pedley, devoted about 7 minutes of his presidential plenary lecture to the MOC controversy (especially Part IV) at the AAN annual meeting in Washington, D.C. this last April, highlighting the burdens for neurologists, also mentioning the American Psychiatric Association opposition to Part IV of the American Board of Psychiatry and Neurology MOC program, ABPN-Letter (1).

The ABMS is not listening.

That’s the problem. There’s no oversight authority above the ABMS which would prevent the imposition of burdensome regulatory policies driven by short-sighted physician executives most of whom are not in clinical practice, as pointed out by Dr. Charles Cutler at the MOC debate on December 2, 2014 hosted by the Philadelphia County Medical Society.

No wonder doctors hope the National Board of Physicians and Surgeons will be vetted. The formation of the NBPAS is an expression of grass roots constructive activism in civil though vigorous opposition to the ABMS, which has lost its legitimacy as a leader in the opinion of many physicians.

Where does that leave rank-and-file doctors? A few will choose to be noncompliant with MOC, although the majority are likely to tolerate it despite deploring it because of local institutional credentialing requirements. Another small number of physicians will support MOC and even praise it. Patients will continue to be generally unaware of the issue because for the majority, certification is less important than access to their doctors.

What sort of compromise would make the most sense? How about enabling boards to track the smartphone use of PubMed search apps and similar practice support tools by physicians regarding the hits to what my former teacher, Dr. Bill Yates, recommended to me recently when I was complaining about the requirement for a smartphone to use the Academy of Psychosomatic Medicine Annual Meeting Mobile App?:

“I have to agree on the value of the smartphone in many areas for docs. MobilePDR and PubMed search apps are great and I would think they would be helpful on rounds. The usability factor for an old man like me really jumped after purchasing a refurbished Samsung Galaxy S5 from Gazelle.com for around $280. Big screen and the fastest Chrome browser in all my computers and gadgets.”–Bill Yates, MD.

That would convince me to buy a smartphone, although it would still have to be a flip phone…to prevent butt dialing. I hope the boards stop pushing doctors around soon…before I retire.

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