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.

Saturday, November 10, 2012

Alphabet Soup

A couple months ago, I spent a weekend working through two modules of PIP (Performance in Practice).

The first came with my Focus subscription from the APA. It's now free to APA members, and $399 to everyone else. It covers assessing for Substance Abuse.

The second was free, and recommended by the APA publication on MOC (Maintenance of Certification). Here's a link to that (i.e. the publication): http://www.abpn.com/downloads/moc/moc_web_doc.pdf.

The site I did the PIP on was Med-IQ, sponsored by Lilly. This one had to do with depression.

I did both these modules just to see what the experience was like. And to try to figure out what exactly PIP is.
To clarify, you have to do several CME-type things to maintain board certification (in addition to taking the written exam).

1. You need to earn an average of 30 CME Category 1 credits each year. So, a total of 300 credits over the 10 year period, with 150 credits in the first 5 years, and the other 150 in the second 5 years.

2. Self-Assessment: 8 of the 30 yearly credits need to be Self-Assessment (SA) credits. This seems to mean that you answer some questions and get feedback on your results, with suitable references for areas of weakness. What it amounts to in reality is that you take a pretest before you read whatever you're reading to earn credits, and find out how you did. Then you read the thing and take the same test, with the same questions, which you already knew the answers to before you read anything because you took the pretest. And you get credit for the post-test. Dumb, no?

3. Performance in Practice modules: Here, you start out in Stage A, where you have to do chart reviews and answer questions about how you're managing your patients. The APA PIP asked for 5 charts. The Med-IQ one asked for 25. It's really not that hard to do-it's just a checklist. And you get 5 CME credits for it (I think SA, not sure).

In Stage B, you determine your areas of weakness based on the chart review, read something relevant that they give you, and then come up with a plan to improve your performance.

Finally, in Stage C, you review charts again. These don't have to be the same charts as in Stage A, but this has to be done at a temporal remove, i.e., after you've implemented your improvement plan. At least a month, or 3 months, depending on which module, but less than 24 months.

4. As part of the PIP, or maybe just the MOC, you need to have 5 colleagues fill out a checklist about how you're doing. You also need to have 5 patients fill out a different checklist about how you're doing.

Here's a snapshot of the phase-in schedule:

And now, the editorializing:

I'm really irked by a system that was created to check up on you and make sure you're keeping up to date, and by doing so, discourages actually keeping up to date, and instead, encourages you to pay money to the APA to get the answers to questions so you can get CME credit without reading anything. Don't we discourage high school students from paying people for the answers to SAT questions? Haven't people gone to jail for that?

Just saying.

And what's up with the APA endorsing a Lilly sponsored activity?

Also, the PIP modules were clearly designed for practices that see patients for 15 minutes every three months, and have a large staff taking care of office stuff.

For example, they asked whether you use various questionnaires or checklists to see if a patient is depressed, and to follow up to see if they're improving. They asked if you use a checklist to assess adherence. There seems to be a checklist for everything, and of course you should use them. They can be easily filled out by the patient in the waiting room.

This is standard of care? Whatever happened to talking to our patients?

I don't have that kind of practice. I see patients for 45 minutes, no matter what. I see a few patients just for medication management, but the vast majority of my practice combines therapy and meds. Therapy done by me. As frequently as four times a week. That's right, four. In analysis. On a couch.

I assess symptoms by asking about them. I assess improvement by asking how the patient is doing, and listening to what the patient tells me. I assess adherence by asking if patients are taking their meds. And they tell me, because they know I'm not going to criticize them. Because they trust me. Because I spend time talking and listening to them.

And I encourage them to criticize me. By talking about their criticisms. Not by handing me a meaningless piece of paper.

Not to mention what a boundary violation it would be to ask patients to fill out a form about me, so I can maintain my certification. It takes so much time and effort to get patients to the point where they feel they can use me in the treatment, rather than doing things for me.

I'm not completely knocking checklists. They can certainly be useful. But they shouldn't be the mainstay of treatment. Better to take a good history.

And where did they get these PIP modules? Have they been validated over time? Did someone just wake up one day and say, this is a good idea, and I'm sure it'll improve patient care even though it hasn't been tested, so we'll make it a requirement?

I'm disgusted that the practice of psychiatry has been reduced to mindless check boxes. But what really gets me is that this is now considered a good thing.