Having graduated with the initial class of residents who were not awarded lifelong board certification, I am among the first cohort of psychiatrists who face the prospect of board re-recertification; in other words, becoming certified for the third time. Building on the report of Sidney Weissman, MD that was published in the Psychiatric Times, there are a number of issues that I expect are very common in those at a similar stage in their careers, and which I share to foster further discussion.
In the first place, as is common in any profession, there has been an evolution in my practice. Early career positions that called for general psychiatric knowledge have given way to a practice centered on treating and evaluating injured workers. As a consequence, I have been called upon to develop expertise in conditions that were largely extraneous to those I treated when I was first board certified, including mild traumatic brain injury, chronic pain, and psychological factors affecting physical conditions, not to mention various issues at the interface of psychiatry and the law. By dint of interest and necessity, I have obtained an abundance of continuing medical education during the past ten years on matters that I knew almost nothing when I was first board certified, and which were only part of my practice when I recertified a decade ago.
Secondly, both the topics that are of interest to me, and the means by which I educate myself on them, do not lend themselves to the CME that is approved by the American Board of Psychiatry and Neurology (ABPN). Officially sanctioned CME is centered on conventional topics in psychiatry frequently provided extraneous to one’s practice, via conferences, on-line lectures, collected readings, or highly contrived self-assessment measures. Whereas one can obtain “approved” CME piecemeal, one hour at a time, the process is labor-intensive and time-consuming, relative to the education obtained.
Thirdly, in keeping with recent writings of Thomas Insel, Allan Francis, and others, my 25+ years of experience as a psychiatrist has made me intolerant of much of the conventional wisdom of psychiatry. For example, the extreme heterogeneity and comorbidity of psychiatric constructs such as PTSD (citation re 640,000) has made me intolerant of talks that treat the condition as well-circumscribed condition. In treating depressed patients who are unemployed, in pain, with maladaptive personality traits and issues with substance abuse, studies of the pharmacology of “treatment resistant depression” leave me cold. The elimination of somatization, pain disorder, and histrionic personality disorder from DSM-5 makes it necessary to turn to the general medical literature to gain insight into what used to be termed “medically unexplained physical symptoms.” In witnessing first-hand the significant limitations of psychiatric nosology and treatment, I have gravitated to psychological studies that provide me context and wisdom. Consequently, combined with either the redundancy or irrelevance of much of what passes for “approved CME,” I find myself increasingly resentful that I am expected to spend 300 hours obtaining education in topics of uncertain validity.
The net effect of the desire to remain on top of my profession while also satisfying administrative requirements is to, in effect, create two categories of CME. One category is captured in the extensive self-directed education that I have obtained over the past ten years, as reflected in the hundreds of academic papers I’ve reviewed and retained in files, the multiple books that I’ve read and kept on my shelves, and the clinical reports I have written. The other category is represented by the content from conferences and material I have purchased through the American Psychiatric Association and other, which I find significantly less useful. The latter category is also frankly difficult to obtain, given the time away that is required to attend conferences.
Like others at this stage in their careers, I find myself highly conflicted over a situation in which official recognition of my expertise must be gained through a labor-intensive, costly process that I believe detracts from self-directed education motivated by my actual interests and professional needs.