Open Letter to ABPN Psychiatry Director: Hey, I’m Unhappy About The MOC

I learned yesterday of an article on Medscape titled “MOC: No Changes for Psychiatry, Neurology Anytime Soon.”

Registration is free to read the article, in which Jeffrey Lyness, MD, psychiatry director for the ABPN, professor of psychiatry and neurology, and senior associate dean for academic affairs at the University of Rochester School of Medicine and Dentistry, in New York is quoted,

“My sense is that overall, our diplomates have been more satisfied than our colleagues,” Dr Lyness toldMedscape Medical News. “It doesn’t mean everybody’s happy,” he said.

“Over time, it’s becoming clearer to people what they have to do, and also, the requirements are getting more flexible,” Dr Lyness said.

For the PIP this year, ABPN diplomates can choose either a clinical or a feedback module. In 2015, the clinical module was required, and in 2014, diplomates were expected to do both. “Now it’s one or the other,” said Dr Lyness.’

In February 2015, the American Academy of Neurology urged the ABPN to eliminate Part IV, and the ABIM has suspended the requirement entirely. The ABMS has said that Part IV is required of everybody, and yet has done nothing to the ABIM, said Dr Lyness.”

 Dr. Lyness further said in reference to the above:

“So we’ve been watching that pretty closely,” he said, but the ABPN is not taking any similar action.

“On the one hand, we do not want to jeopardize our certificates by doing something that eventually has the ABMS telling us that we’ve invalidated our certificates,” he said. “On the other hand, if the ABMS is really not going to make Part IV required, we may not want to require it either.”

For now, “we’re an ABMS member board, and we adhere to the ABMS requirements,” said Dr Lyness.

In September 2015, the American Board of Anesthesiology said it was replacing the 10-year examination with an online learning tool that quizzes physicians on a continuous basis. Shortly thereafter, the ABIM said it was considering eliminating the examination and replacing it with a similar model of continuous online testing.

Dr Lyness said that the anesthesiology board had briefed the ABPN on its model, which is “clearly allowed by the ABMS.” The psychiatry board is “in concept open to alternatives,” he said, but it is investigating how such a test would be administered, whether it would be a reliable measure, and whether a small number of questions every month or every year would be less or more burdensome.

In looking at the MOC overall, “we have to balance credibility with cost and the burden or convenience factor for our diplomates,” said Dr Lyness, adding that the ABPN was “trying to steer a reasonable ground.”

I’ve always thought that direct action is preferable to making comments on articles which hardly anyone reads. I respectfully disagree with Dr. Lyness and just mailed my opinion today to him, which I’m making public as an open letter below:

 

Dear Dr. Lyness:

I’m a Clinical Professor of Psychiatry at UIHC and I’d like to take exception to your remarks in the March 22, 2016 Medscape article titled “MOC: No Changes for Psychiatry, Neurology Anytime Soon.”  I think that, while it may be accurate to say that “…our diplomates have been more satisfied than our colleagues…” it’s probably also true that the ABPN does not hear what rank and file diplomates may really think about MOC because they might believe there is no point in trying to fight it anymore.

I notice that this article was published almost exactly year after a similar Medscape article was published on the same topic, “Psychiatrists: No Problem with MOC?” There were 29 comments posted which disagree with the title’s implication and there are no comments posted so far on the current article. Although this might be interpreted to imply there is less opposition, I think it means that psychiatrists are tired, and feel helpless to change the regulatory pressure which contributes to the nearly 50% physician burnout rate. My comment from last year:

Well, I disagree with Dr. Bernstein so thoroughly I doubt that the comment section has enough space in it for what I have to say. I have not renewed my APA membership this year because I don’t think the $981 fee and the lack of representation of my interests is worth the trouble.

I have personally authored resolutions to support the principle of lifelong learning and oppose both MOC and its cousin Maintenance of Licensure (MOL) and they have both been approved by the Iowa Medical Society.

I’m also inquiring into our credentialing department to see if our university would accept adding the alternative board recently started by Dr. Paul Tierstein, the Nation Board of Physicians and Surgeons, because it doesn’t require participation in the MOC.

I teach medical students and residents every day about the importance of the principle of lifelong learning and the need for the next generation of doctors to cultivate a systematic way of integrating it into their professional lives. MOC is not the way.

All of the residents and medical students I talk to about the MOC fear it. So why do I beat the drum so hard? I want my trainees, the next generation of doctors, to know I stood up for them.

 

The NBPAS is gaining adherents from all specialties, including psychiatrists. I think of the NBPAS as one of the many indicators of how frustrated doctors are about MOC.

I introduced resolutions to the Iowa Medical Society supporting the principle of lifelong learning but opposing Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) which were both adopted in the last few years. I happen to be board certified in Psychiatry and Psychosomatic Medicine and I plan to take the last recertification examination for the former in the next couple of years because I intend to retire soon after.

I think most psychiatrists are not vocal in opposition to MOC and MOL because of inertia and fatalism, not because they agree with these processes. I have participated in a conference call to the Iowa Board of Medicine opposing MOL, which ultimately decided not to implement MOL in Iowa. Part of the reason I have opposed these processes is that I believe strongly they could hurt retention and recruitment of primary care and psychiatric physicians to our state.

Board certification has become a bone of contention especially in the past five or six years. I discovered about a year ago that our hospital, a much-awarded tertiary care referral center staffed by world class clinicians and researchers doesn’t even require board certification, much less MOC participation, as a bar for faculty appointment and hospital privileging.

I have been teaching medical students and residents as a faculty member here since my graduation from residency in 1996 and I can tell you that I try to foster a devotion to developing clinical excellence, not just competence. The MOC gets in my way and I never miss an opportunity to show my trainees what I believe reflective self-improvement means for me and my patients.

In fact, the best example of how we practice continuous self-improvement is on my blog site, https://thepracticalpsychosomaticist.com/ . There you can see many examples of practice-based learning in the form of the Clinical Problems in Consultation Psychiatry (CPCP) case conference. I’ve also started a Psychosomatic Medicine Interest Group (PMIG) which meets monthly and is also a case-based group learning approach to practice-based learning and improvement.

I can tell you that I still field questions from my colleagues about the ABPN MOC process, which is confusing, burdensome, and viewed as busy work which takes time away from patient care. While I welcome the small changes made by the ABPN including the recent relaxation of the Performance in Practice (PIP) clinical module for which a Feedback module can now be substituted, I believe the ABPN could do much more to ease the recertification burden.

The American Psychiatric Association (APA) has been clearly opposed to the current structure of the MOC and it has called for elimination of Part IV and for consideration of modifying the recertification examination structure as well. Doctors don’t learn this way anymore, especially in the age of electronic devices which allow instant access to medical literature indices.

I have shared my opinion with Dr. Larry Faulkner, MD, President and CEO of the ABPN more than once. I have even submitted a PIP clinical module for assessment and management of delirium, which was pre-approved.

Every single day I’m doing much more toward clinical self-improvement than the ABPN MOC could ever accomplish.

Like you, I’m doubtful that a small number of questions every month or every year would be less burdensome than a secure recertification exam every 10 years. However, with medical knowledge growing so quickly nowadays, I also doubt that a 10 year exam should count as a valid measure of how current a physician’s knowledge base is.

As a consulting psychiatrist for an 800 bed academic medical center, I can tell you just how much I think MOC has improved the practice of Iowa’s physicians—not one jot. I continue to see overdiagnosis of psychiatric illness and polypharmacy overprescribing which neither the MOC nor so-called “light touch intervention” by sending polite government letters to physicians telling them to stop it has done much to change [1].

We must do something different from MOC in order to improve safe and effective patient care. MOC has not been shown in high level studies to improve patient outcomes or to improve the doctor-patient relationship [2, 3]. In fact, I think it could potentially worsen outcomes in some cases by taking time away from direct patient care to participate in empty exercises which are not relevant to anyone’s practice.

Many physicians, including psychiatrists, think the ABMS and member specialty certification boards have lost their way and lost the trust of physicians, believing that it is past time for them, as Drs. Westby Fisher and Edward Schloss advise, to “…remove all requirements for time-limited board certification and resort to conventional self-selected ACGME-approved CME programs for ongoing professional education [4].”

I marvel that my medical students and residents are so enthusiastic about their futures in medicine. It grieves me to tell them the hard truth about our system, but I am duty bound to be frank with them. No one else will. Their perseverance tells me they must love the profession almost as much as I do. I could not be more proud of them.

Please help me remove the obstacles to their success and build a better path to fostering excellence.

References:

  1. Sacarny, A., et al. (2016). “Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers.” Health Aff (Millwood) 35(3): 471-479.
  1. 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.
  2. 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.
  3. Fisher, W. G. and E. J. Schloss (2016). “Medical specialty certification in the United States-a false idol?” J Interv Card Electrophysiol.

I urge all interested psychiatrists with a stake in this matter to mail letters to Dr. Lyness. I don’t know if a lot of letters will change his mind, but it’s worth a try.

Advertisements

Comments

  1. William Marks says:

    The medical industrial complex…

    Like

  2. Bravo. ABMS-MOC (TM) trademarked secure tests never achieved either content or predictive validity for evaluating the “minimally-competent” subspecialist among already-Board-certified diplomats. MOC was / is a huge burden, a dark stain, on the careers of already Boarded physicians and surgeons. The MOC programs have hurt rather than helped physician practices and they hurt advanced patient care. How did this MOC mess occur? MOC secure tests involved an unaccountable, unaudited, and high-revenue testing monopoly whereby test designers used peculiar variations of an elementary education and industrial task-designed scoring standard, modified Angoff, for complex professional scenarios where even correctly-utilized Angoff scoring systems have been known to fail. AND there have been manipulations of test contents between candidates. AND there have been no validations of the judges or subject matter experts, SMEs, in scoring these processes, either among themselves for inter-rater reliability, or for their relevance in the profession at large. In fact, ABIM short cut the number of questions rated in order to minimize judge fatigue. All have been abominations against conscientious, highly-trained, well qualified physicians and already Boarded diplomats. “You cannot justify or correct what you bundled by design.” END MOC entirely, 100%, now, and let medical research, scholarship, education, and lifelong learning flourish again … as before 1990, before the onset of the horrendous MOC green testing industry. Board certification should be for LIFE: Once and Done for Everyone. When MOC ceases, perhaps physicians and surgeons might display their time-unlimited Board certificates with pride, as before 1990, before the onset of the controversial, dark MOC programs.

    Liked by 1 person

%d bloggers like this: