Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, May 4, 2014

Coming Up Empty

This one surprised me.

I was reading an article in the May 2014 edition of Psychiatric Times, An Update on the Maintenance of Certification Program for Psychiatry, by Patricia Vondrak, MBA, and Larry Faulkner, MD.

Notice, there's no link to the article. That's because I couldn't find it. Surprise #1.

I went to the Psychiatric Times site, and I searched under the title of the article. Nothing (Actually, 3 links to "Update on Opioids"). I put quotes around the title. Nothing. I tried the authors' names. Nothing. I looked under the "topics" heading for "practice management", which this section claimed to be in the print edition I was reading. Nothing. The print edition had a sidebar heading, "Special Report", so I checked the special reports section. Nothing. I did everything again and checked my spelling. Nothing.

This did not bode well.

The article describes:

The 4 components of the MOC process:

  • Professionalism and Professional Standing
  • Lifelong Learning and Self Assessment
  • Assessment of Knowledge, Judgement and Skills
  • Improvement in Medical Practice

It had a bunch of FAQs, number 5 of which was:

Why is CME required for Part 2 of the ABPN MOC program?

CME ensures that professional development activities have been developed according to rigorous standards, including avoidance of conflict of interest. (emphasis mine)

Really? You think Pharma-sponsored CME is rigorous and free of conflict of interest? I mean, no one believes that, and most people are resigned to it, but you really have the Chutzpah to blatantly state it in a publication?

I admit that while I was peeved, I was not surprised by this last.

I was excited about one part, though:

The ABMS provides an evidence library on their Web site that highlights research studies and articles that support the value of board certification and MOC. It reflects an effort to systematically present the empirical evidence in the current peer-reviewed literature.

I was excited because I thought, Okay, I'll check out the evidence library, and maybe I'll be reluctantly convinced that MOC is helpful, or maybe I'll find some article I can fiendishly try to refute, because that's just irresistible given how peeved I am.

I went to the evidence library.

I clicked on "Topics: Validation of Current MOC Programs". 34 hits, including articles on Family medicine, diabetes, lower back pain. I really just glanced. Then I restricted to "2010 to current", because I figured MOC now is very different than MOC in 2000. 14 hits. Then I went to keyword, "psychiatry and neurology", which they had listed-I didn't need to type it in to a search box.

Surprise #2, no hits.

I tried the same sequence, but with years 2000-2010. No hits.

I started over and changed the topic to "Value of Board Certification".  Out of curiosity, I clicked the first link, appropriately entitled, Specialty Board Certification and Clinical Outcomes: The Missing Link, published in 2002. The authors looked at studies from 1966-1999. They started out with 1204 papers, but by the time they pared the list down to good studies that met their criteria, they had 13, from which they identified 33 "separable relevant findings".

Of the 33 findings, 16 demonstrated a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes for certified physicians, and 14 showed no association... Meta-analytic statistics were not feasible due to variability in outcome measures across studies.

Their conclusion:

Few published studies (5%) used research methods appropriate for the research question, and among the screened studies more than half support an association between board certification status and positive clinical outcomes.

Surprise #3-16 is more than half of 33!

I went back and went through the same timeframe and keyword search, and got no hits.

I went through the same process with the "framework and structure" topic, and again, no hits.

Maybe it's naive of me, but I really expected SOMETHING. I'm kind of disappointed. I was all ready for a fight.

Well, I guess I did find something. I googled the authors' names, and I ended up on the abpn site. Larry Faulkner is the President and CEO. I guess I'm lame for not realizing that to begin with. And Patti Vondrak is Director of Examination Administration.

Did you ever hear the expression, "The patient has GMG?" It's old medical slang for a patient with many complaints but no findings, and it stands for Gornisht Mit Gornisht, which is Yiddish for, "Nothing with Nothing". And as Shakespeare so famously wrote, "Nothing will come of nothing."


  1. Nice commentary on the lack of substance behind MOC. Did you see this recent post on The Last Psychiatrist? I think you and TLP both hit the nail on the head...

    1. Thanks! It's a brilliant piece. For those of you reading this comment, please link to it. It's called, The Maintenance of Certification Exam as Fetish.

  2. I confess I've been reading about MOC from the sidelines, in part because my board certification is grandfathered in — I missed the renewable certification by a year or two. Sounds like a hot mess though, and I'm grateful that you and others are writing about it.

    As chair of CME at a large medical center, I feel compelled to say something about CME and Pharma. Conscientious institutions like ours go to great lengths to review CME presentations in advance — checking the CVs of presenters, going through their PowerPoint slide-by-slide — to ferret out even subtle conflicts of interest. The national oversight body, ACCME, has "Standards for Commercial Support" that are fairly stringent, even through the eyes of someone like myself who has been concerned about this issue since the 1990s. Among many other provisions, commercial sponsors must offer unrestricted grants, and have zero influence on the selection of speakers or the content of the talk.

    I've been to CME where this was clearly not the case, particularly prior to ACCME tightening its rules some years back. If Pharma were prohibited from sponsoring CME it would make my job a little easier, although to be honest the real challenge is otherwise qualified speakers who have financial ties to industry, an entanglement that is nearly impossible to avoid and usually much harder to resolve. In my view CME from reputable educational institutions (as opposed to for-profit MECCs) may not always be perfect, but it remains medicine's best hope for unbiased professional education. Of course, how this applies to MOC depends on additional factors, not the least of which is whether there is anything to teach.

    1. Thanks for the comment. I've been looking at the ACCME site, and I think it tries, but the rules are a little malleable. The CME I'm thinking of, though, is more online stuff, not through talks at conscientious institutions. And the MOC requirements for CME are such that you have to try to get it where you can. If you want to do a performance in practice module, you can use FOCUS, which is published by the APA, for a price, even for members. If you want to do a free PIP module, you can find these online, but they're sponsored.
      Actually, the reason I was looking at the ACCME site is that I was thinking of writing a post about what's involved in qualifying for category 1 CME. I haven't been through the site carefully yet, but at first glance, it seems expensive. So despite the fact that I learn much more from writing this blog than I have from any standard CME activity, and I hope other people learn from it, too, No one can get category 1 CME.

    2. The online stuff is called "enduring materials" in CME parlance, and can come from reputable or less-than-reputable sources. Caveat emptor.

      Qualifying to provide category 1 CME is an involved process (and presumably expensive, although I don't know as much about that). The idea is that quality assurance is hierarchical: ACCME accredits institutions, then the institutions accredit individual CME offerings. (And in some places, e.g., here in California, an intermediary such as the California Medical Association's "Institute of Medical Quality" acts on behalf of, and in coordination with, ACCME to do the actual regional accreditation.) Last Friday I was at an all-day conference of California CME providers, going over the myriad rules and regulations that we providers must follow before we are authorized to declare a talk suitable for CME. It should go without saying that there are countless highly educational experiences that do not qualify for CME — hospital rounds is a good example. This is much less problematic than experiences that DO qualify for CME but are not educational.