On The American Psychiatric Association Elections 2017…And Other Thoughts

Today is the last day American Psychiatric Association (APA) members can vote in the 2017 election. Even though I am not a member, I’ve gotten email messages from one candidate, Dr. Brian Crowley, MD, who is running for APA Secretary. One of his main campaign issues is abolishing Maintenance of Certification (MOC). When I asked him what his specific plan would be for abolishing MOC, his reply was, “If elected we will move to abolish MOC and appoint a very short term work group to detail the strategy; it has been done by other specialties in medicine. Could have to change boards if needed.”

I also was struck by Dr. Crowley’s remark about the voter turnout in last year’s election, “Can you believe, last election 80% did not vote?! Don’t leave your future up to the few who do. Make your opinions known and acted upon.”

That sounds familiar. In 2011, I posted about the poor voter turnout  regarding the APA Member Referendum ballot about the Maintenance of Certification (MOC) for psychiatrists, to be voted on by APA membership in the 2011 APA election. This was a mass email sent to all APA members. Those who remember this failed ballot will recall why it failed.

As background, the email was a request to vote against the American Board of Psychiatry and Neurology (ABPN) “burdensome” MOC Performance in Practice (PIP) requirements, which were slated to become mandatory by 2013 for those applying for MOC examinations in 2014. The specific objection to the requirement for patient feedback was that it could create ethical conflicts and interfere with treatment.

Furthermore, the referendum stated that the requirements other than a cognitive examination once every 10 years, regular participation in medical education, and maintenance of licensure posed undue and unnecessary burden on psychiatrists. The sender had submitted a petition co-signed by 797 other APA members leading to the referendum.

Here’s what happened: 80% of the voters supported the statement but because only 25% of the members voted rather than the 40% needed, the referendum failed to pass. The referendum garnered a higher percentage of votes than any of the candidates running for office.

I also asked Dr. Rahn Kennedy Bailey, MD the same question, noting that he is running for APA President. My question is still “awaiting moderation” and I think I’ll probably not be getting an answer. My question is below and he can still choose to answer it.

I’m a psychiatrist at The University of Iowa Hospitals & Clinics and have been a conscientious objector to MOC for several years. I’m speaking as an individual and not as a representative of my employer. I support the principle of lifelong learning.

I remember Dr. Renee Binder running for APA President in 2014 and she too was publicly opposed to MOC. After she was elected, I didn’t hear much from her on how specifically she would abolish MOC as it’s currently configured. Both you and Dr. Brian Crowley, who is running for APA Secretary, are running for APA offices based on a commitment to abolishing MOC. How specifically would you accomplish that?

I was pretty disappointed in APA after 2014 and, as a consequence of the lukewarm commitment to opposing MOC and supporting llfelong learning, I did not renew my membership. That doesn’t mean that I think APA has done nothing about changing MOC. The APA has formally asked the ABPN to eliminate Part IV, but ABPN has not done so. The APA has not yet asked the ABPN to eliminate self-assessment or the examination.

What is your plan?

I note that under Dr. Bailey’s campaign item “MOC and Scope of Practice” he writes “No psychiatrist should be forced to maintain their underlying general and subspecialty certification through more than one certification process.” This sounded familiar and it turns out it’s lifted from the APA Board of Trustees message to ABPN President Larry Faulkner, M.D in 2015 (by the way, he earned over $900,000 in 2014 according to IRS Form 990):
• “APA does not agree that there should be an exam every 10 years for MOC.
• Certification of lifelong learning should be an integrated, ongoing process relevant to actual practice.
• APA is willing to work with the ABPN to improve the MOC process.
• For subspecialists taking a recertification exam, the ABPN should ensure that the exam primarily consists of questions related to the diplomates’ subspecialty. Any general psychiatry questions that are included should be relevant to the diplomates’ practice.
No psychiatrist should be forced to maintain her/his underlying general and subspecialty certification through more than one certification process.

I don’t think much of the answers or non-answers of this year’s APA candidates. I’m not an APA member so it probably doesn’t matter to them. This is probably part of the reason why Dr. Bailey doesn’t answer my question about how specifically he would guide the APA process toward negotiating a more practical solution to the challenges in assisting rank-and-file psychiatrists in pursuing lifelong learning in the service of safe, high-quality patient care–other than by empty campaign promises to abolish MOC.

Instead of lamenting the poor APA election turnout numbers, maybe the candidates could turn their energies to the kind of constructive activism which has already led to some changes in how the American Board of Medical Specialties (ABMS) member boards foster physicians to develop systematic practice improvement. What? Yes, I just said that some people believe the ABMS has changed.  At least that’s how the leaders of the National Board of Physicians and Surgeons (NBPAS) view their role in advancing change.

Recall my questions to NBPAS about their alternative certification process. Here are my questions and the answers in red:

1. Why does NBPAS certification require previous ABMS member board certification? Doesn’t this requirement keep us dependent on the ABMS? How would new medical school graduates avoid ABMS member board certification, which requires MOC participation? Wouldn’t the requirement for previous ABMS certification be a disincentive to certify with NBPAS, since that requires paying for two certifications? NBPAS offers an alternative for re-certification, not initial certification. We do not find fault in ABMS’ initial certification, only in their MOC.
2. And what happens to the NBPAS certification holder when the ABMS certification expires? Does that mean the NBPAS certification also expires? When I presented the case supporting NBPAS at a faculty meeting, this issue was raised by one of my colleagues. If your ABMS board certification has lapsed, NBPAS can still certify you. For certification for the first time through NBPAS, we would require 100 hours of CME obtained in the past 24 months at the time of certification.
3. If certain private insurance payers require MOC participation, how does NBPAS compete with ABMS? The payer issue is one we are very much aware of and is the top priority for NBPAS in 2017.
4. Is the goal of NBPAS to provide a practical alternative to ABMS, or to somehow persuade the ABMS to change? Both. Though we’ve seen significant changes in ABMS since the inception of NBPAS in 2015, we still are moving forward with working on gaining NBPAS acceptance.

I had a couple of extra questions, which NBPAS also promptly addressed:

If NBPAS “offers an alternative for re-certification, not initial certification” could a newly graduated resident be certified by NBPAS without going through the initial ABMS member board certification route? The application process seems to indicate that because it says “CME requirement is waived for physicians -in-or within 24 months of training who supply either a letter from their program director or copy of their program diploma indicating date of training within 24 months.” Yet the next application requirement says the applicant needs “Previous certification by an ABMS or AOA member board.” While we waive the CME requirement for fellows looking to acquire NBPAS certification, they are still required to have initially obtained ABMS or AOA board certification to be considered. I’m sorry our language is confusing. 

For the next question I used myself as an example: My ABMS board certification will expire in 2018 if I don’t take the recertification exam. If I obtain NBPAs certification now (so that for a short time I’d be certified by both ABMS and NBPAS), would I remain certified by NBPAS after my ABMS certification expires and then would I be able to recertify with NBPAS with CME credits and the fee—without renewing the ABMS recertification? Yes, you are correct that your NBPAS certification would still remain valid after your ABMS member board certification lapses. That being said, you can also apply to NBPAS if your ABMS certification is already lapsed; this would require 100 hours of CME. 

That said, I’m not sure why anyone thinks there has been a fundamental change in either the policies of the ABMS or the American Board of Internal Medicine (ABIM). Certainly, the ABMS public online position on their MOC 2015 standards seems unchanged. I was one of the 625 physicians who submitted comments during the two-month comment period in 2014 leading to the 2015 standards. And the leadership of the ABIM seems hopelessly mired in their attempts to gain any traction from diplomates regarding the steady erosion of their view of the legitimacy of the board’s authority.

Ironically, while some think the American Board of Psychiatry and Neurology (ABPN) has not changed, the February 2016 announcement from the board indicated that it essentially eliminated the Performance in Practice (PIP) component of Part IV of the MOC: No one who doesn’t want to work on the PIP Clinical Module actually has to because they can substitute a Feedback Module.  This was ABPN’s work-around for implementing its suggestion to ABMS to make Part IV itself optional (from ABPN letter to ABMS: “Based upon the feedback we have received from the AAN and the APA, the ABPN has respectfully asked the ABMS to consider modifying its 2015 MOC Standards so that Part IV is an optional component of MOC”).

Predictably, the ABMS rejected the suggestion to make Part IV itself optional. However, the ABPN change accomplishes almost the same thing. The caveat is that one could argue that the Feedback Module is essentially meaningless. One could ask for “feedback” from a colleague or department chair which doesn’t necessarily offer guidance toward substantive change in attitude or behavior, and which could be limited by the lack of acceptance or even appreciation of the feedback, especially if it’s viewed as coming from someone whose authority to offer it is not seen as legitimate.

In the end, it’s this tendency for us to view the legitimacy of authority of our professional societies and boards with skepticism that ultimately keeps this cycle of conflict going. The flip side of the coin is that we could say it’s the tendency of boards and other professional organizations to burden us with MOC busy-work and pick our pockets for board exam fees and membership dues that keep the cycle going.

This is probably one of the reasons why APA members don’t vote. This is probably why some APA members drop their memberships.

This is probably one of the reasons why a lawsuit was filed in federal court against the ABMS MOC.

This is probably why the state of Oklahoma passed a law in April, 2016, stating that nothing in its laws concerning medical practice shall be construed to make MOC “a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” Kentucky’s governor signed a more limited measure that forbids making MOC a condition of state licensure. Other states are considering joining Oklahoma as “Right to Care” states”–Dr. Karen Sibert, MD, from her blog post “The Boards Have Exceeded Their Bounds” Jan 16, 2017. 

This is probably one of the reasons why NBPAS was formed. And so on.

If you’re an APA member, you should probably go ahead and vote. Maybe you should not expect too much. Or maybe you should.