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.

Wednesday, February 18, 2015

Another Board

I'm still so appalled by the whole MOC experience, that I applied for Board Certification in Psychiatry through the National Board of Physicians and Surgeons. I can't remember if I wrote this in a past post or not, but when I checked out their site previously, it didn't look like they offered certification in general psychiatry-just subspecialties. But that seemed weird, so I went back and looked again, and cemented my belief in good design. I know that seems like a non-sequitur. But see what I mean:

This is a segment of the list-there are more subspecialties, as well as other specialities. None of the phrases is a hyperlink. So it looked to me like "Psychiatry and Neurology" was just the heading. But it's not, and they do offer it.

They require your medical license number and registration expiration date, a single pdf that includes certificates for 50 CME credits in the last 24 months, and a fee of $169, or $29 if you're within two years of your training, that covers two years of certification. And for an extra $18, you can get a paper certificate "with gold seal suitable for framing". Turnaround time for certification is six weeks or less.

They also provide two sample letters, one to "Credentials Committee, MEC, Chief of Staff, administrators, or insurers", and the other to colleagues, as well as a general summary "to educate your hospital’s Medical Executive Committee, administrators, colleagues, and patients, about why NBPAS certification is important", explaining the controversy over board certification, their requirements for certification, and with some references.

Their position is as follows:

There is controversy surrounding the requirements for continued certification in a medical specialty. Many physicians believe recent changes requiring physicians engage in various medical knowledge, practice-assessment, and patient-safety activities as well as recertification exams do not provide optimal use of physician’s time. Furthermore, no high quality data exist to justify these labor intensive and expensive activities.

Some of their more important FAQs:

They're a grass roots organization trying hard to gain acceptance by hospitals and payers.

The application fee goes to the cost of maintaining the organization, and to ultimately spreading the word and lobbying hospitals, payers, and politicians to accept this certification. They hope to lower application fees, going forward. Also, thus far, physician management has not taken any salary.

There's a bit about the FSMB's proposed Interstate Compact, and whether it will require ABMS MOC. NBPAS's take on this is that the FSMB claims this is a myth, but that they're not so sure, so better to get cracking and be accepted by the FSMB as an alternative board, before that happens.

I don't know much about the Interstate Compact, but here's a link to an overview, and another to their list of myths.

This was a bit of an impulse buy for me. I was reminded of the NBPAS by an anonymous comment on my post, I Really Should Be Studying..., with links to their site, as well as the AAPS page with information about the Interstate Compact. My thanks to anonymous.

I don't know exactly what this certification is worth-I'm basically paying $187 for a piece of paper-or if it's any better or worse than the ABMS. But I do think the ABMS needs some good old market competition, at least to keep down fees. And since I really don't plan on taking another MOC exam 10 years from now, when the blintzes hit the fan, I don't want to be standing around without at least SOME certificate to cover me.

Saturday, February 14, 2015


In response to my post, GASP!, a friend sent me some links to articles about acupuncture. Specifically, acupuncture was compared with counseling and treatment as usual for depression.

What is "counseling"? I've heard the word used any number of times, and I think I just assumed that it's what people say when they don't want to say "therapy", because they think "therapy" sounds too stigmatizing. Or it's therapy as practiced by someone not specifically trained in therapy,  per se, like the clergy.

But maybe not. Is it therapy? A specific kind of therapy? How does it differ from therapy, if at all? Who practices it, and why are they called counselors rather than therapists? Why would someone want counseling rather than therapy?

I Googled "What is counseling", and I got some interesting links.

There's the American Counseling Association, which offered this definition:

Professional counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. 

They provide further detail:

Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health.

Okay, so counseling is some kind of professional relationship involving mental health.

According to the site, there are 4 different types of counseling: Individual, Couples, Family, and Group. There's a little blurb about each of these, and interestingly, the Family blurb, but none of the others,  uses the word, "therapy".

There are a number of counseling specialties, including but not limited to:

Career and employment
Adult Development and Aging/Gerontology
LGBTQ issues

and something called, "Assessment". When I clicked that link, it explained:

Counselors, educators, and other professionals advances the counseling profession by promoting best practices in assessment, research, and evaluation in counseling. Assessments are a systematic way to obtain information about the client’s problems, concerns, strengths, resources and needs.

Does this mean some counselors specialize in taking a history? I can't tell.

There are state licensure requirements. There are also 2 certifying boards, although certification is not required.

The National Board for Certified Counselors requires passing an exam, the National counselor Examination (NCE).

It also requires:

-Master’s degree in counseling or with a major study in counseling from a regionally accredited institution
-3,000 hours of counseling experience and 100 hours of supervision both over a two year post-master’s time period
-Post-master’s experience and supervision requirements are waived for graduate students who have completed CACREP accredited tracks.

I don't know what those tracks are.

The Commission on Rehabilitation Counselor Certification (CRCC) is the other board. It has its own exam, and a number of ways of meeting eligibility criteria for certification, which seem to involve supervision, work experience, a Master's or Doctoral level degree in Counseling or Rehab Counseling, or an advanced degree in one of 13 areas:

Behavioral Health                         Psychology
Behavioral Science                       Psychometrics
Disability Studies                          Rehabilitation Administration/Services
Human Relations                          Social Work
Human Services                           Special Education
Marriage and Family Therapy         Vocational Assessment/Evaluation
Occupational Therapy

I still don't understand the difference between counseling and therapy. I found a site with a piece called, "Psychologist v. Counselor". It claims that:
-Counselors usually have a master's level degree, and generally don't do research, or perform psychometric testing, though some get further training to so they can.
-Some psychologists get licensed as counselors.

Psychologists are more likely to work with individuals with serious mental illness. They are trained to perform psychotherapy with a range of clients, but in many settings, general therapy roles will go primarily to counselors and other master’s level mental health practitioners. The reason? These individuals are more cost effective.

Bottom line: I still don't know what counseling is. It seems like "counselors" have a certain type of training, +/- certification, with varying backgrounds and degrees. But what they do remains a mystery to me, although it sounds like therapy.

Thursday, February 12, 2015


I took my MOC exam today. I probably passed, but I'd forgotten what it's like to take an exam and really not have a sense of how it went.  I certainly didn't bomb it, but I didn't crush it, either. (It seems like those verbs should be interchangeable).

Was it like the practice questions? Somewhat. But the content didn't seem to be represented in the same proportions. There were no questions involving drug interactions and CYP 450 stuff. Only one MAO-I question. And a much smaller percentage of mood disorder questions than I expected and prepared for. At the same time, there were more questions involving somatic symptoms than seems representative of what one might see in practice, relative to MDD and bipolar, or schizophrenia, for that matter.

I found the medication questions fairly straightforward. But there weren't that many. There were a LOT of personality disorder questions, with what felt like a disproportionate number where the answer was Narcissistic PD. At least I hope it was.  In a way, the PD questions were easy-I don't have difficulty identifying diagnostic criteria. But when it comes to the statistics of the various PDs, I don't know that much.

The friend with whom I studied for the exam took hers a couple days ago. She felt like the questions were easier than the ones we had reviewed, which is probably true, when they covered the same topics the review questions had. She said she had a lot of child questions she didn't feel that prepared for. I had almost no child questions, but quite a few GeroPsych ones, for which I felt moderately prepared. I also had more forensic questions than I expected, and those covered topics I wasn't that familiar with.

The one area I felt was represented in the way I expected, both proportion and content, was substance. I think Beat the Boards did a good job preparing me for those. And there was one question that came straight out of the practice exams-about trichotillomania and habit reversal training as treatment.

My friend and I had a long study session last weekend. She brought along a problem book that a friend of hers from work had given her, and we used that to supplement the Beat the Boards problems, The book is, Study Guide to Psychiatry: A Companion to the American Psychiatric Publishing Textbook of Psychiatry, Sixth Edition, by Philip Muskin. I'd say the questions were a little harder than the beat the boards ones, and there were occasional inconsistencies between the two sources, but the explanations were mostly helpful. I think it's probably worth looking at, if you're in the process of preparing for the exam, and it does include the DSM IV to DSM 5 transition material.

The exam took me a total of 2 hours, including the tutorial at the beginning, a bathroom break in the middle, and the survey at the end. I should have, but didn't bother to write in the survey that not all the meds referenced in questions were listed in the drug guide, which is a screen you can pull up to find the brand name that goes with the generic in the question. There is an allotted 5 hours for the exam, which is 220 questions long. As a gauge, I'm not a fast test-taker. I just either knew the answer or didn't. If I didn't, I either guessed completely randomly-and there were fortunately very few of those questions-or I made an educated guess after narrowing it down, but I didn't spend long deliberating (in New York medical circles, they say "davening", but I don't know if that's a regional thing).

The testing site reminded me, both from a visual and olfactory perspective, of the 1980s suburban industrial building in which I worked as a programmer during one summer in high school. It had the same mix of small to middling companies looking for reasonably priced infrastructure and willing to situate themselves right next to a highway to get it.

The test center was pleasant enough. They took palm prints and checked them every time I went in and out of the testing room. There was a large "ergonomic" desk chair at each cubicle, which did nothing for my bad back, but that's just me. They had what they referred to as "noise reduction headphones", which were just headphones with big puffy ear pieces covered in little hygienic shower caps, with absolutely no noise reduction technology. They gave me a dry erase board and marker, which I never used. My stuff was placed in a locker, which I could access on breaks, if I wanted to. The bathroom was down the hall.

The results are meant to be mailed to me in 8 weeks. It's hard to understand why it takes 8 weeks to score a computerized exam, but there you are.

So I'm done. Or I hope I am. I don't care for multiple endings, like in The French Lieutenant's Woman. And I've heard people complain about the dragged out ending of the Lord Of The Rings. I read someplace that Tolkien planned the ending from early on, but I always liked it, because I didn't want to leave Middle Earth.

If I failed and have to retake it, I suppose this is Frodo and Sam being carried out of Mordor by the giant eagles. But hopefully, I didn't fail. And if that's the case, I don't plan to take it again, ever. Either the world will have come to its senses and done away with the exam in 10 years, or I just won't take it. So hopefully, this is the Grey Havens.

Tuesday, February 10, 2015

I Really Should Be Studying, But The ABPN Is Too Outrageous

My MOC exam is in 2 days. I'm headed into the home stretch right now, and I plan to spend tomorrow memorizing CYP 450 stuff, as well as various elimination half lives. Oh, and seeing patients. 

But I got this email just now, and I'm reproducing it in full. I can't figure out if the people who write this crap actually believe it. Look at the ABPN patting itself on the back for having already put in place the changes the ABIM plans to implement!

Check it (and the boldface is theirs, not mine):

Dear Diplomates,

The purpose of this letter is to respond to inquiries from many American Board of Psychiatry and Neurology (ABPN) diplomates concerning the recent communication from the American Board of Internal Medicine (ABIM) about changes it plans to make in its Maintenance of Certification (MOC) Program.  The ABIM has now pledged to engage the internal medicine community in an effort to make its MOC Program more relevant and meaningful for physicians involved in patient care and clinical leadership.  While all 24 Member Boards of the American Board of Medical Specialties (ABMS) have agreed to follow its MOC Standards, the specific manner in which those standards are met is largely up to the Member Boards.  It is gratifying to note that most of the changes now planned by the ABIM are consistent with policies and practices already in place in the ABPN MOC Program.
At the heart of the ABPN MOC Program are several core beliefs that serve as the foundation for our specific requirements.
The ABPN believes that the vast majority of its diplomates already pursue life-long learning.  The main tasks for the ABPN MOC Program are to support the ongoing professional development of our diplomates and to reinforce and document their life-long learning efforts in a manner consistent with the expectations of outside organizations and the public. 
The ABPN believes in a collaborative approach to MOC.  We work very closely with our related professional societies like the American Psychiatric Association, the American Academy of Neurology, and virtually every subspecialty society.  We encourage those societies to develop relevant MOC products for their members and we have a streamlined process in place for the review and approval of those products.  We also recommend that societies provide those MOC products to their members for free or at reduced cost, and many societies have recently followed our recommendations. 
The ABPN believes that it must avoid any potential conflict of interest in its MOC Program.  We develop no MOC products other than the MOC examinations, and we depend upon our professional societies for the development of MOC products for self-assessment, CME, and performance improvement.
The ABPN believes that its MOC requirements must not place an onerous burden on diplomates.  As a result of recent feedback from diplomates, we significantly reduced the self-assessment and performance improvement requirements for diplomates in our 10-Year MOC Program.  We also recently made a decision to give 3 years of MOC credit to diplomates who have completed accredited subspecialty training and passed our subspecialty certification examinations.
The ABPN believes that it is crucial to allow diplomates to select the specific MOC products that best fit their needs for self-assessment, CME, and performance improvement.  We have never required that diplomates complete specific MOC activities that are not relevant to their own practices.  With the flexibility afforded in the new 2015 ABMS MOC Standards, we recently expanded the range of options available for diplomates to meet its self-assessment and feedback requirements.
The ABPN believes that it is important to recognize and give diplomates MOC credit for what they do already.  We know that many diplomates work in organizations requiring quality improvement and feedback activities that are very similar to our MOC requirements, and we want to recognize those diplomate activities.
The ABPN believes that the vast majority of diplomates should be able to pass its MOC examinations.  All of our MOC examinations are clinically relevant and have reasonable passing standards.  To date more than 95% of diplomates have passed our MOC examinations, and diplomates are given two chances to pass an MOC examination before their certification is rescinded.
The ABPN believes that it must only report whether or not diplomates have met its MOC requirements.  While we encourage diplomates with “life-time” certificates to participate in MOC, we also maintain our covenant with them by being clear that they are not required to do so.  We also recently modified our requirements to make it easier for our "life-time" diplomates to enter our Continuous MOC Program should they choose to do so.
The ABPN believes that diplomate attestation and random audit are acceptable methods to document their performance in MOC.  We never require diplomates to submit any MOC or practice data to the ABPN. 
The ABPN believes that its MOC fees must be reasonable.  We carefully review MOC fees annually.  Fees in our 10-Year MOC Program were reduced 25% in 2008, another 6% in 2009, and will be reduced another 7% in 2016.  All total, MOC fees will have been reduced 34% since 2007 and are at a level significantly below the average for all Member Boards.
While the ABPN recognizes that its MOC Program is continuously evolving, we are planning no other changes in our MOC requirements at this time.  The ABPN is continually looking for more ways to improve its relevance and flexibility and to reduce the burden it places on our busy diplomates.  As we have done in the past, we welcome any constructive recommendations in that regard.  Our sincere hope is that the ABPN can be seen by diplomates as an important ally that can help them to document their life-long learning for their patients and those organizations who license, credential, and pay for their services.  We commit to doing all we can to make that hope a reality. 
Dr Faulkner sig .tif
Larry R. Faulkner, M.D.
President and CEO

Tuesday, February 3, 2015


Across Gorgoroth, Ted Nasmith

I'm deep into crunch time for my MOC exam, which is next week. Do I feel adequately prepared? No. Or, well, it's hard to say. I'm relying on the Beat the Boards practice questions to be representative of actual questions on the exam.

It occurred to me recently that when I studied for the initial certification written exam, I had old PRITEs to use for sample questions. Now I don't. When I check on Amazon, there are a bunch of books for the initial exam, but none for the re-certification. And they're different exams, in that they cover different topics, e.g. no Neuro on the MOC, so I can't just use those question sets. 

I've been keeping a running list of factoids that I think I should remember, including a bunch of statistical facts. Kinda hard to retain them. My memory is adequate to the task, but I don't like memorizing. Maybe it's my math background, but I much prefer to remember a few basic principles, from which I can deduce what I need to know. That approach went out the window in medical school, but I'm still wistful.

So here's my list, in no particular order, of stats for the MOC. If writing them again helps me remember them, great. If other people find them useful, great. If not, well, what can I say.

5-10% of whites are poor CYP 2D6 metabolizers.

10% of patients with bulimia are male.

20-50% of erectile disorders have an organic basis.

PCOS in 10% of patients taking valproate.

80-100% of pedophiles describe themselves as heterosexual.

1% of the general population
8% of non-twin sibling
12% 1 parent
12% dizygotic twin
40% 2 parents
47% monozygotic twin
30% of patients who are compliant with meds relapse

A patient who is hospitalized with a first episode MDD has a 50% chance of recurrence in 5 years.

8.5% of Americans meet criteria for EtOH Use D/O (DSM 5)
Lifetime prevalence of alcohol dependence (DSM-IV) is 12.5%.
With treatment, 50-60% maintain abstinence after 1 year
20% get better without treatment
20% never get better
DTs in 30% of patients with EtOH w/d seizures
15-20% mortality in untreated DTs.

90-95% of tobacco users relapse within the first six months of quitting

25% of patients with autism develop seizures by adolescence

5-10% of Alzheimer's patients develop the disease before age 65

25% of hospitalized medically ill patients with delirium will die within 6 months of discharge

10% develop a benign rash on lamictal

Suicide 9-10%
50-70% with h/o physical or sexual abuse

There is evidence of substance use in 50% of drivers killed in MVAs.

Please be liberal with comments and corrections.