Category: consultation-liaison psychiatry

I’m back on my soap box about Maintenance of Certification (MOC) again. Sidney Weissman, M.D. remarked in a letter to the editor of Psychiatric News (April 19, 2019 issue, Vol. 54, No. 8) on the rising numbers of graduating medical students who match in psychiatry residency slots. Many will graduate from these programs into private practice clinics which will emphasize seeing large numbers of patients primarily for medication management. Psychiatric hospitalists like me are uncommon, which tends to decelerate the movement toward integrating medical and psychiatric care and limits the application of psychotherapy which psychiatrists have historically done but which has been replaced by medication management.

While the match numbers continue to grow in psychiatry, the dissatisfaction with regulatory pressures from certification boards like the American Board of Psychiatry and Neurology (ABPN) also continue to frustrate psychiatrists who are compelled to oppose the Maintenance of Certification (MOC). Indeed, another prominent story in the psychiatric news is the class action lawsuit against the ABPN filed by two psychiatrists, alleging that the MOC requirements are illegal and anticompetitive. See the story in the April issues of Clinical Psychiatry News and Psychiatric News.

Along with the increasing numbers of psychiatrists who are retiring (more than 60% of psychiatrists are over the age of 55), and I interpret the increasing Psychiatry match numbers with cautious optimism at best.

I have always advocated for the principle of life-long learning for physicians and opposed MOC because, in my opinion, it’s a drag on the progress of fulfilling the principle. The reason is that there is very little evidence supporting the certification boards’ assertions that MOC makes better physicians.

I have supported the position of Dr. Paul Teirstein, MD, one of the leading physicians spearheading the National Board of Physicians and Surgeons (NBPAS), and I’ve recommended that the University of Iowa Hospitals and Clinics (UIHC) consider accepting NBPAS as an alternative to the American Board of Medical Specialties (ABMS) MOC. Three Iowa hospitals already do so.

I’ve been in phased retirement and expect to be fully retired by 2020. Because of that, I decided not to seek continued certification through either NBPAS or ABMS. I chose not to pay the fee required by the American Board of Psychiatry and Neurology (ABPN) to sit for the recertification examination. Consequently, that resulted in my being identified as “Certified” although “Not Meeting MOC Requirements.” This was data about me as a physician which was readily available to the public and other organizations. I think it’s unfortunate that this practice tends to convey the impression some physicians are less qualified than others based on their certification status alone.

Now I’m listed on the ABPN as “Not Certified” of course. Ironically, my Performance in Practice (PIP) module on delirium, the Delirium Clinical Module is still there. You can find it just by typing the word “delirium” in the search field. In my previous blog, The Practical C-L Psychiatrist, there was virtually no interest in such a module, at least judging from my far from scientific poll about 6 years ago. Yet it’s one of the few modules available on the ABPN website that C-L psychiatrists would welcome.

I’m aware that declining to sit for what would have been the last MOC recertification examination in my career might not be viewed as much of a protest, especially since I’m retiring.

I’m also aware that many physicians are not in a position to decline participation in MOC. Some organizations and health insurers demand it, prompting several physicians and state legislators to collaborate toward adopting or consider adopting laws to discourage it.

To be fair, MOC is often not the only criterion that organizations use to ensure patients are getting the best health care available. And there are many who work diligently to improve the MOC process and believe it works. Enhancing the motivation for physicians to participate in MOC is complicated and we need to consider different practice environments, physician burnout, and financial incentive programs which have typically attracted few physicians overall.

It’s difficult to find much information on PubMed about MOC, whether you search using the Most Recent or the Best Match filter. In both, I found a paper by a doctor which appeals to my sense of humor as well as to my sense of fair play. It was written by a Singapore physician, for whom the dollar cost of recertification was over $10,000. His nerves took a beating as well as his bank account. Speaking of banking, here is the authors’ final observation:

Physicians should be able to choose a programme that best fits their scope of practice. However, it is likely that, besides the efforts put in by physicians themselves as a commitment to professionalism, the economic price will be borne by patients in the name of public assurance of medical competence and safety. If the burden becomes too onerous, one can always become a banker. — Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.

I’m a very busy consultation-liaison psychiatrist in a large academic medical center. I think there are alternatives to MOC which don’t waste my time with modules and tests which typically are not relevant to my practice.

For example, I have followed the model of the practice-based learning and improvement competency at the University of Iowa by using what Drs. William R. Yates and Terri Gerdes called the “problem-based learning” case conference. The abstract for their paper describes it:

“Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.”

This is now called the Clinical Problems in Consultation-Psychiatry (CPCP) and trainees from medical students to residents participate as presenters. The format is also used as a framework for the Consultation-Liaison Psychiatry Interest Group at Iowa. There are lively discussions at these meetings, to which colleagues from other medical specialty departments are invited. The model for this was adapted from that reported by Puri and colleagues.

Yet these and other creative practice-based learning efforts which are relevant to our practices are not on the approved product list for CME and Self-Assessment at the ABPN.

To be sure, one Performance in Practice (PIP) clinical module (mentioned above) that I and one of our residents submitted to ABPN was approved. This was the Delirium Clinical Module, for which we received congratulations from leaders of the Academy of Consultation-Liaison Psychiatry (ACLP). This is a clinically relevant exercise which could be useful to many medical specialists, not just psychiatrists. It would also be important for enhancing patient safety—which is the whole idea of practice-based learning.

I have worked with the Iowa Medical Society (IMS) to get resolutions adopted as IMS Policy which support the principle of lifelong learning and which oppose both MOC and Maintenance of Licensure (MOL).

The idea that if doctors don’t develop a system for monitoring continued competence in psychiatry, other groups will do it for us likely comes from what are essentially cases of medical malpractice. This was probably what was meant by the ABPN response to my criticisms of the MOC process several years ago, which was that part of the reason for MOC was the public’s demand for a way to hold physicians accountable for harming patients.

One of the papers citing this problem was by Shaw and colleagues. The authors mention “damaging high-profile cases” one example of which triggered the Bristol Inquiry in the United Kingdom leading to the “development of a compulsory integrated regulatory program with oversight in all levels of medical care from hospital systems to the practice of individual physicians.

This is the United Kingdom’s revalidation program, which is similar to MOC or perhaps more properly, MOL.

The irony is that the American Board of Medical Specialties (ABMS) and member specialty boards including the ABPN claim the American version of MOC is a voluntary program and that this is “self-regulation.” It’s not clear who else would “do it for us” though—some government agency? It’s hardly necessary when, as Dr. Paul Mathews reported recently, some private insurance payers require participation in MOC. He’s a voluntary board member of the National Board of Physicians and Surgeons (NBPAS), which is a newly established alternative to the ABMS which doesn’t require MOC participation:

“WHAT DO PRIVATE PAYERS GAIN FROM REQUIRING MOC?

As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements”

This raises another concern about MOC, which is the ever-present cloud of suspicion the ABMS and some of the member specialty boards are under, especially the American Board of Internal Medicine (ABIM).

According to Charles Cutler, M.D., M.A.C.P., in the winter 2016-17 issue of Philadelphia Medicine, Philadelphia County Medical Society, in an issue entitled “Is The ABIM Too Broken to Fix?” article “A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires,” reforms should in fact include doing just what the title says and much more.

Board executives, especially CEOs, make what appear to be enormous six-figure incomes from the MOC programs, including Dr. Larry Faulkner, M.D., the President and CEO of the ABPN who earned over $900,000 in 2014 according to IRS Form 990.

Those with a low opinion of the adage about “…the wise old doctor who improves with experience…” should probably be shared with those board leaders who made the arbitrary cutoff date for requiring participation in MOC, grandfathering physicians board certified prior to 1994, thereby exempting them from the program.

Participation in MOC would make more sense if there were credible research evidence that it improves patient outcomes. However, the studies tend not to support this conclusion.

And MOC is not supported by most physicians, according the results of a Mayo Clinic Proceedings survey, indicating that “Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.”

Finally, any suggestion to sign up right away for MOC probably should be preceded by another important action, which is to first check with your institution to see if MOC participation or, indeed, board certification itself, is a condition of employment. It may not be.

What are the alternatives to the MOC approach? They depend on one’s level of attachment to keeping some sort of certification status.

There is the alternative National Board of Physicians and Surgeons (NBPAS), which was launched in 2015 and offers board re-certification without MOC or recertification examination requirements. There is a nominal fee and CME requirement. A previous ABMS certification is also required, but if that has lapsed one can still obtain certification by submitting a higher number of CME credits.

NBPAS leaders are very much aware that certain private insurance payers require MOC participation. It was the top priority for NBPAS in 2017. See their website for full details about their re-certification process.

Physicians could simply forgo MOC or alternative certifications, which would probably raise more anxiety. For example, if one simply stops sending money to the ABPN toward MOC requirements and declines to sit for the recertification examination, then after the general board expires one would be identified as “Certified-not meeting MOC requirements.” But after the examination date passes, you’re Not Certified. The prudent diplomate should first check with ABPN for clarification of specific details and should check their employer’s expectations and insurance payer rules about MOC.

In my opinion, there ought to be a choice to participate in MOC or some other vehicle for fulfilling the principle of lifelong learning. Those who want MOC should keep it. Those who don’t should be allowed to continue using the method they’re most comfortable with for maintaining their knowledge and clinical skills, including CME and other creative methods for staying current with the medical literature.

Our patients deserve at least this much.

“It is far better to light the candle than to curse the darkness”—attributed to William L. Watkinson in a 1907 sermon according to Quote Investigator.

William L. Watkinson

References:

Pato, M. T., et al. (2013). “Journal club for faculty or residents: A model for lifelong learning and maintenance of certification.” International Review of Psychiatry 25(3): 276-283.

Brooks, E. M., et al. (2017). “What Family Physicians Really Think of Maintenance of Certification Part II Activities.” J Contin Educ Health Prof 37(4): 223-229.

Tieder, J. S., et al. (2017). “A Survey of Perceived Effectiveness of Part 4 Maintenance of Certification.” Hosp Pediatr 7(11): 642-648.

Stoff, B. K., et al. (2018). “Maintenance of Certification: A grandfatherly ethical analysis.” Journal of the American Academy of Dermatology 78(3): 627-630.

Glover, M., et al. (2017). “Participation and payments in the PQRS Maintenance of Certification Program: Implications for future merit based payment programs.” Healthcare.

Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.

More References:     

1.         Boland, R., MD, Maintenance of Certification, in Psychiatric Times. 2017, UBM Medica.

2.         Knoll, J.L., IV, MD; Cotoman, Dan, MD, Maintenance of Certification and Self-Mortification, in Psychiatric Times. 2017, UBM Medica.

3.         Shanafelt, T.D., L.N. Dyrbye, and C.P. West, Addressing physician burnout: The way forward. JAMA, 2017. 317(9): p. 901-902.

4.         Bright, R.P. and L. Krahn, Value-added education: enhancing learning on the psychiatry inpatient consultation service. Acad Psychiatry, 2015. 39(2): p. 212-4.

5.         Yates, W.R. and T.T. Gerdes, Problem-based learning in consultation psychiatry. Gen Hosp Psychiatry, 1996. 18(3): p. 139-44.

6.         Puri, N.V., P. Azzam, and P. Gopalan, Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics, 2015. 56(3): p. 268-73.

7.         Shaw, K., et al., Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA, 2009. 302(18): p. 2008-14.

8.         Mathew, P., MD, MOC and Physician Burnout: Treating the Cause, Not the Symptoms, in Practical Neurology. 2016.

9.         Cutler, C., MD, MACP, A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires, in Philadelphia Medicine: The Official Magazine of the Philadelphia County Medical Society Philadelphia Medicine 2016, Hoffmann Publishing Group, Inc.

10.       Gray, B.M., et al., Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA, 2014. 312(22): p. 2348-57.

11.       Hayes, J., et al., Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA, 2014. 312(22): p. 2358-63.

12.       Cook, D.A., et al., Physician Attitudes About Maintenance of Certification. Mayo Clinic Proceedings, 2016. 91(10): p. 1336-1345.