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.

Monday, November 16, 2015

Here Goes Nothin'

I did it. I just now submitted an application to the American Board of Psychiatry and Neurology (ABPN) for approval of an Improvement in Medical Practice Clinical Module. That's the notorious, MOC Part IV Performance in Practice (PIP) module.

I don't expect much to come of it, although I was inspired to make the attempt by Jim Amos at The Practical Psychosomaticist, who submitted his own CL module. Brave man.

Let's review. In order to maintain board certification by the ABPN, psychiatrists no longer need to submit the Part IV feedback modules, which asked for reviews from 5 peers, and from 5 patients. But, we still need to do those idiotic practice improvement modules, one every three years. You take 5 patient charts. You go through them to see if you're meeting "evidence-based" practice standards in a specific area, like depression, for example. And they HAVE to be based on some "evidence-based" guideline.

If you're not meeting the standards, you implement the suggested "evidence-based" changes, which mostly involve questionnaires like the PHQ-9, and then two years later, you do another chart review to see if you've gotten your act together by then and have been using PHQ-9's with all your patients. Then you've demonstrated improvement.

Of course, if you were doing things "right" to begin with, then two years later, you will have failed to improve because you haven't implemented any changes. It's my understanding that some people understate what they're doing in the initial review, or outright lie about it, so they can demonstrate improvement two years later. I didn't do that. I just documented that I made none of their recommended changes because they weren't clinically appropriate.

My version is a Psychoanalytic PIP. I considered starting it back in a post I wrote in July, Fascinating, but I had trouble finding a suitable Practice Guideline. Well, I subsequently found one, the American Psychoanalytic Association's (APSaA's) Practice Bulletin 7: Psychoanalytic Clinical Assessment. This is an interesting document, with a lot to say about the limitations of the DSM system, and the risks of diagnosing a patient:

The current DSM system does not include information derived from psychoanalytic
research methods and, with a few notable exceptions, ignores the accumulated
knowledge from a century of psychoanalytic clinical experience...For example, the DSM-IV system does not account for unconscious aspects of mental functioning that are at the heart of the psychoanalytic treatment process. The DSM-IV perspective aims to confine its data to experience and behavior at the level of phenomena that can also be observed outside a therapeutic context. In contrast, a psychoanalytic perspective recognizes unconscious processes and unconscious meanings of experience and behavior as these become observable over the course of treatment. Some examples are intra-psychic conflict, defenses and their associated internal object relations, ego functions, the cohesiveness of the sense of self, the patient's subjective inner life experience, etc....

Clinical use of "official" diagnostic labels tends to act as a suggestion that might become a new guiding aspect of the patient's sense of self and might serve to alter the treatment process. In some cases, this suggestive technique might help a patient who feels fragmented to organize his or her sense of self enough to participate more effectively in treatment. However, the experience of being labeled with "the diagnosis" may create new defensive barriers that can block free psychoanalytic exploration and obstruct the treatment process. 

It has a section about assessment of strengths, to determine a patient's suitability for analysis, and this is what I used for the PIP module. The relevant parts of the module application look like this:

I chose "Type of Treatment" as my category, and I listed the practice bulletin as the guideline to be used. As it turns out, the bulletin has exactly four clearly delineated categories in the assessment of strengths section, so that worked out well.

1. Motivation: How clearly and seriously does the patient see the presenting problem(s) and how does this relate to the patient's determination to pursue an analytic effort at self-exploration? How stable is the patient's current life situation and how strongly is the patient willing and able to invest the effort, time, and financial resources necessary for successful psychoanalytic treatment?

2. Potential for self-observation: How strong are the patient's capacities for introspective self-reflection, cognition, verbal communication, and expression of thoughts, feelings and fantasies?

3. Potential to withstand the tensions of analysis: How strong is the patient's capacity for impulse control and frustration tolerance? How effectively has the patient utilized prior treatment opportunities?

4. Potential to work analytically: To what degree does the patient show abilities for adaptive internal conflict resolution (e.g., via sublimation, grief and mourning, etc.), for maintaining a loving, caring investment in a human relationship in the face of some frustration (object constancy), for recognizing and experiencing others as both similar and different from oneself (e.g. self-object differentiation), and for reliable recognition of the difference between reality and fantasy (reality testing)? How strongly does the patient show the potential to analyze rather than avoid or mal-adaptively enact the anticipated powerful feelings, wishes, and urges that emerge toward the analyst?
I included only the headings in the application, and I attached a form I made up that delineates the specific details under each heading.

Then I included this description of procedure:

Chart review of 5 patients to determine suitability for psychoanalysis. Patients may be in psychoanalysis currently, or in another modality of treatment. See attached pdf of module questionnaire. If patients are suitable for psychoanalytic treatment, then either continue with psychoanalysis if already in progress, or switch them from their current modality to psychoanalysis. If patients are not suitable for psychoanalysis, then switch them from psychoanalysis to another suitable modality, if they are currently in psychoanalytic treatment, or continue with current treatment. Follow up in 2 years to determine if patients are being properly assessed for appropriate treatment.

And that was basically it, aside from attaching a pdf of my nice form, modeled after the PIP modules I've done already:

What this module addresses is the question: Is the patient suitable for analysis?

It doesn't address the question: Is analysis suitable for the patient? So you can't really jump directly from noting that a patient is suitable for analysis to starting an analysis.

I thought about including this question in another section, but I didn't for several reasons. First is that the practice bulletin doesn't directly treat this topic. It makes reference to it, but not as clearly as the four topics under "Strengths". And while determining whether a presenting problem is suitable for analysis is part of analytic training, I wanted something simple and boldly stated, so that whoever evaluates this doesn't have an excuse to reject it.

Also, the application asks for a minimum of 4 measures, so I gave it 4 measures. I'm not doing any extra work for this nonsense. I don't really expect the application to be approved, so I didn't try all that hard. I assume the ABPN won't think the practice guideline is "evidence-based" enough. Or perhaps my phrasing is not in line with what they think of as measures of quality. But who knows? If they approve it, I might actually do a PIP module and consider maintaining my certification status. I'll just have to wait and find out.

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