Signed, Sealed, Delivered

My ABPN recertification certificate was delivered today. It was maximally inconvenient, because it had to be signed for. It says:

The American Board of Psychiatry and Neurology

Incorporated 1934

Member of the American Board of Medical Specialties

hereby declares

Me, MD

maintained certification in Psychiatry

on February 9, 2015

as a Diplomate of the American Board of Psychiatry and Neurology

Ongoing certification is contingent upon meeting the requirements of

Maintenance of Certification

Then it has the signatures, certificate number, and a blurb about certification being contingent on maintaining licensure.

First of all, shouldn't it be, "declares that?"

In the lower left hand corner is the seal of the ABPN:

And in the lower right hand corner is the seal of the ABMS:

I'm not sure how well you can see the ABMS seal, but the cap stone of "Excellence" rests on the three pillars of "Ethics", "Honor", and "Skill".

And the Latin ribbon reads, "Animus Opibusque Parati" or, "Prepared in Mind and Resources," which is, apparently, one of the mottoes of South Carolina. The other is, "Dum Spiro Spero" or, "While I Breathe, I Hope."

What about those images on the ABMS seal? I get the staff of Asclepius on the left, but the oil lamp on the right? Master Google didn't come up with a quick answer for me, but I'm thinking, genie? Maybe the three pillars of excellence are really just the three things the ABMS wishes it had. Or maybe it's that Neti Pot thing you use for nasal irrigation.

I don't know what the link is between the ABMS and South Carolina, but this is probably not the state you want to be linked with right now.

Silliness aside, what do you think of that, "Ongoing certification is contingent upon meeting the requirements of Maintenance of Certification?" Would you hang that on your office wall? I won't. It's like the ABMS wants your patients to think, "Hm, is my doctor still board certified? Maybe I should check." Just another way of intimidating doctors into keeping up with MOC.

The certificate came with yet another advertisement from Jim Henry, Inc., for ordering a frame. I'm so glad I didn't get one. My plan is to put this new piece of card stock away someplace, and remove the little rectangle that states that my certification expires at the end of 2015 from the frame on my present certificate.

MOC Survey Results

I've now closed my MOC survey on SurveyMonkey, so let's talk about the responses. There were 11, which is nowhere near as pathetic as previous surveys I've conducted. To those of you who responded, you have my thanks.

To those who didn't, there will always be opportunities down the line, so you didn't miss out too much.

As a reminder, this was a one question survey, and that question is:

Would you be willing to openly boycott the ABPN and refuse to pay the annual C-MOC fee until the Part IV requirement is removed and an effort is made to demonstrate the usefulness of a 10 year exam?

And now, the big reveal:

Most of the people who responded to my survey would be willing to boycott. Since I limited myself to one question, I don't know why the person who wouldn't be willing to boycott feels that way. Or for that matter, why the other 10 feel the way they do.

It might have been interesting to get that information, but my sense is that the shorter the survey, the more likely people are to respond.

What now? I don't know. If the survey is representative of the greater population of C-MOC psychiatrists, then it would be worth trying to organize something. But there's obviously no way to know if it is.

To be honest, I'm a little sad thinking about it. I feel like I don't have the motivation or energy (or time) to push for something organized and bigger, but maybe I would if I thought more people would join me. And I'm guessing that's the way a lot of us feel.

So maybe we stage our own little, individual protests by not paying the annual fee, but we're not formally together as a group, so maybe it doesn't have that much impact. Or maybe money talks regardless of whether the same amount is being withheld by one large collective, or by individuals.

It still feels kind of isolated.

What would you do with this?

There and Back Again

The Hill: Hobbiton-across-the Water, by JRR Tolkien

I passed my MOC exam.  Friends and family have been teasing me about worrying that I wouldn't pass. I think it was a mild to moderate worry that I wouldn't pass, versus the severe unpleasantness of the consequences of not passing.

I found out 5 weeks to the day after taking the exam. The ABPN emailed me and told me I could check my score on ABPN Folios, although that would just indicate pass or fail.

They also sent information via mail, including my exact score, a breakdown of my sub-scores, a breakdown of the exam by section, and other information, which I'll get to later on.

One piece of information for people planning to take the exam soon, that I don't think I knew before the exam, or maybe I did, is that the passing standard for 2015 is 66%. I got an 85%. I wasn't planning to share the details of my scores, and it makes me a little uncomfortable to do so, but on consideration, I decided that it might be helpful to see how I did, compared with how I prepared and how I thought I did-see my posts, Done, Percentages, and The Evil Emperor MOC.

So here's the chart I came up with:

I had felt there were proportionally fewer Mood d/o questions. This seems to be a distortion on my part, although it's possible the Mood d/o questions were closer to 11%, and Psychotic, Substance and Anxiety were all closer to 15%. But it's good to know that the bulk of what psychiatrists see was represented in the largest proportion.

I had mentioned that I thought there were a lot of Personality d/o questions. I guess I was right about that. I was also right about the fact that I wasn't as well-prepared for these questions, reflected in my score of 77%.

I had felt well-prepared for the substance and neurocognitive d/o questions ( I don't think I mentioned that latter, in my previous post, but I talked to colleagues about it), and this is also reflected in my scores.

I don't take the lower "% of Exam" area scores very seriously. Like, maybe there were two questions on Dissociative d/o's and I got 1 wrong.

So it looks like I was reasonably well-prepared for the exam. My only advice to people about to take it would be not to bother with CYP-450 stuff, and focus more on personality d/os.

Now for the "back again" part.

The score report came with other information about MOC. Specifically, I'm now automatically enrolled in C-MOC, or Continuous Maintenance of Certification. My new board certificate no longer has an expiration date. I was pleased when I read that part. I thought, well, maybe I won't maintain my MOC, but I'll at least feel like I'm maintaining it.

Most of you reading already know this, but just in case, C-MOC consists of 4 parts. 1. Maintain professional standing. 2. 90 CME category 1 credits, including 24 Self Assessment (SA) credits, every three years. 3. Exam every 10 years. 4. Performance In Practice (PIP) once every three years.

Plus, you have to attest to completed MOC activities annually, and there's also an annual fee of $175, and here I'm quoting:

The annual fee covers maintenance of Board certification status, use of personalized Physician Folios account with customized MOC tracker, development and administrative costs of MOC examinations, including credit towards an MOC examination in a 10 year period.

How much does it cost them for me to "maintain" my board certification status-in other words, do nothing? And I already have a Folios account with a hard-to-use MOC tracker. As to development of MOC exams, I feel like, if I'm paying for it, I should be able to contribute to the decisions about what's covered on the exam. And if the $1750 total is only a "credit towards" another exam, what extra charges am I gonna get?

To me, it sounds like the ABPN is becoming aware that not only are they not the only game in town, but they better make sure to get you hooked in right away, because 10 years down the line, they're likely to lose you.

I thought somehow, by magic, having taken and passed this last exam, I would be spared having to give it a thought for another 10 years. I figured I'd rack up my 300 CME credits, ignore the SA credits, because some time in the next 10 years, the SA thing will be exposed for the racket it is, and be removed. Same for the PIP stuff, which is already circling the drain. And then 10 years from now, the dust will have settled, and I can decide whether it's worthwhile for me to take another exam, or if the ABPN and the ABMS have become a total joke, and my other board certifications are all I need. That's part of the fantasy, that in 10 years, I'll have multiple, non-ABPN, board certifications.

It was not to be. Some time in the next year, I have to decide whether I want to pony up the $175 to continue this trajectory, or take a stand opposing the shameful scam of MOC.

Did you know that in the 2nd Harry Potter movie, Harry Potter and the Chamber of Secrets, there is a large painting of Gandalf just over the door in Dumbledore's office. So in the words of that other great wizard:

"Dark and difficult times lie ahead. Soon, we must all face the choice between what is right, and what is easy."

Leaving the Shire, Ted Nasmith

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.

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. 

Sincerely,

Larry R. Faulkner, M.D.

President and CEO

ABPN

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."

Webinar F/U

I mentioned in my last post that I was going to be participating in an MOC Update Webinar sponsored by the AAPS. Let me start off with a disclaimer: I don't agree with a lot of the views of AAPS, but they have some important ideas, and contributions to make, including their suit of the ABMS (American Board of Medical Specialties), so I find them useful.

The webinar didn't cover much new territory. Some highlights:

The main speaker, Paul Kempen, touched on something I'm not sure I agree with, but that I thought was interesting. Namely, the idea that the Performance In Practice (PIP) modules, which involve implementing the use of rating scales, and then following up on patient outcomes, is a form of using patients for research without their specific consent.

There's a lot of corruption-kickbacks, conflicts of interest, among the higher-ups in the ABMS. Even without the corruption, it costs doctors a lot of money to recertify, and even though ABMS is not-for-profit, executive salaries can hover around $1 million a year.

The ABMS is not regulated, and calls itself the sole official monitoring body. In fact, it doesn't do any monitoring of incompetence, in the form of disciplinary actions. And of course, there is no evidence that it improves patient care.

One question pointed out that if you're being judged on the basis of improved outcomes, such as lower blood pressure, and your licensure is riding on that judgement, you might just tend to "round down" a patient's BP.

Those doctors participating in PQRS will be financially penalized if they don't maintain certification.

Even those physicians who are grandfathered in will have to take a recertification exam by 12.31.23, or they will be given the official descriptor, "Certified Without Meeting MOC Requirements".

Exam questions are clinically irrelevant, out of date, or inaccurate.


What scares me is the way Maintenance of Licensure (MOL) is insinuating itself into the picture. If the ABMS is trying to promote itself as the only game in town, what better way to make sure it stays that way than to make licensure dependent on participation in MOC/recertification.


If you'd like to watch it, you can view the webinar in full here.