S.A., It Aint So

In the hilarious and highly underrated movie, Moving, starring Richard Pryor, the main character (Pryor) loses his engineering job of 15 years. Before he storms out of his boss's office, he gives him the finger, only it's his index finger. He then ruminates for days over his humiliation in using, "The wrong finger!" Ultimately, it becomes a family joke.

You Tube Link

Somehow I was reminded of this scene when I was pondering what to do about my self assessment (SA) MOC credits.

I've been dutifully filling out my CME credit details on the American Board of Psychiatry and Neurology (ABPN) site, and I have more than enough credits to take my recertification exam in 2015.

yay.

But I'm short 1 SA credit.
One.
O.N.E.

You may recall from my Alphabet Soup post, or you may not but feel free to link to it, that if you were board certified in 2005, you need 40 SA credits.

I got all 39 of my SA credits from The Carlat Report (TCR). And until a couple months ago, I planned to continue using TCR to complete my SA credits. It was simple. Instead of just taking a post-test for CME credit, I would take a pre-test that asked the same questions. Then I'd read the material, and then take the post-test and get my certificate. That way, I had assessed myself, and I could tell that I had learned something.

That's the idea, anyway. In reality, I could have simply taken the pre-test, which gave me all the correct answers, skipped reading the material, and filled in the answers on the post-test.  And then I would have learned nothing.

The SA requirement was really well thought out, don't you think?

Then TCR changed it's SA policy, and now they have a separate, yearly package:

We are now offering a NEW self-assessment CME product that consists of 12 monthly issues of The Carlat Psychiatry Report, plus a bonus 120+ pageMedication Fact Book. This inclusive product is $377 and is worth 18 Category 1 CME credits and 8 ABPN SA credits.

The subscription can be purchased at any time in 2014, but all tests must be taken by December 31, 2014, at which time SA credit will be awarded. 

This happened when I was one credit short, can you believe? And even if I were to switch over to the new product, it's not clear to me from the description if I can get a credit or two at a time, or if I have to take the whole test and get 8 SA credits at the end of the year (I've asked them about it, but the answer was slightly vague, and seemed to corroborate my suspicions). Since I'm taking my exam in 2015, I would like to have my credits out of the way earlier than the end of this year.

What to do?

I checked the ABPN site, and they have a page with a list of all their approved SA products, most of which are day or weekend seminars that cost more than I care to spend.

The one I decided to do was a Mass General Academy online module in general psychiatry. 50 questions, 4 SA credits, 35 bucks.

I was, of course, expecting the same deal: pretest, read, post-test. But there's nothing to read. Just 50 questions to answer. They don't report your score to the ABPN, but they give you feedback on how you did.

This was convenient for me, but the questions were not great. Here's an example:


48. Which one of the following hypnotics is free of daytime sedation and significant memory impairment:

a) diazepam.
b) flurazepam.
c) triazolam.
d) zolpidem.

Now, clearly, they want you to answer "d) zolpidem", which I did. But honestly, if you were prescribing Ambien for someone who'd never taken it before, would you feel okay telling them they'd be free of daytime sedation and significant memory impairment?  Does a period of time when you don't know where you were or what you were doing and later found out you rammed your car into a truck not qualify as "significant memory impairment"? Tell that to Kerry Kennedy.

Point being, MOC is a racket that costs time and money, and takes time away from patient care and from actual learning. Maybe a board recertification exam MIGHT be worthwhile if it asked questions that were accurate, up to date, and relevant to real world practice.

What questions, you ask?

Let's make some up.

With which of the following would you choose Brintellix as first line treatment for depression?

a) United Healthcare
b) Blue Cross/Blue Shield
c) Aetna
d) Medicare


Okay, enough with the sarcasm. What I'm really thinking is that it would be great if every practicing clinician would submit one or two questions to a giant question bank, and then self-assessment CME, or even board exams, could be generated from that bank.

The questions could reflect, for example, practices that are bread and butter for someone working in one specialty, and more obscure and likely forgotten, or never learned, for someone else. Like, I could come up with a Psychoanalysis question, and Jim Amos from The Practical Psychosomaticist could come up with a C/L question, and George Dawson over at Real Psychiatry could come up with an Addiction question.

Alternatively, the questions could be ones that don't have clear answers, and would require a little looking into, and maybe some discussion with colleagues. For instance, I have this theory that when it comes to antidepressants, there are SSRI people, and there are non-SSRI people. Is there a way to tell, a priori, who's who? I think this is a question that David Healy is interested in researching. But without clear research, it would be nice to have that discussion with other psychiatrists who are dealing with the same dilemma. When faced with a new patient, I kind of know how I go about deciding, but it's more of a hunch than anything else, and of course, there's always the business of trial and error.

All I'm saying is that there are so many better and cheaper ways to generate lifelong learning than stupid APA endorsed SA CME. Like POLL (Psychiatry Online Lifelong Learning), our free online journal club. Please check it out.

Tomorrow, I'll be joining a free MOC Update Webinar sponsored by AAPS, We'll see if they have anything to say about the SA business.

Lifelong Learning-A New Frontier

This post is tangentially about Maintenance of Certification (MOC). So before I get to the main point, I want to refer readers to Jim Amos' blog, The Practical Psychosomaticist. The link will take you to a form letter to oppose MOC and MOL (Maintenance of Licensure). Dr. Amos generously gives me top credit for it, but it's actually a letter he sent to the AMA and APA, that I modified to make it convenient for other people to use.

Check it out, consider how you feel about MOC and MOL, and if you're so inclined, mail it off.

I've already written about my feelings regarding MOC. So let's get to the main topic, Lifelong Learning. Let's assume the world suddenly becomes a sensible place, and the inane requirements for MOC are done away with. No expensive recertification exam, no dumb PIPs, no useless CME credits. I still consider it my obligation to stay current, so I can take better care of my patients.

What I do now, and would probably continue to do in the aforementioned utopia, is subscribe to The Carlat Report and UpToDate. The Carlat Report doesn't take money from drug companies or other sponsors. And UpToDate is just an excellent resource all around. And no, they're not paying me to write this. (Full Disclosure: I was paid by The Carlat Report for my article in their May edition, but that's the extent of my financial relationship with them).

I've also recently subscribed to NEJM's Journal Watch Psychiatry, but I'm just testing it out at this point, so I can't comment.

But here's a new idea. Or maybe it isn't new, but I don't know about it:

Online Journal Club!

It's the kind of thing that LinkedIn and Facebook lend themselves to. Post a free article online, maybe once a week, allow some time for people to read it, and then ask people to write in and discuss it.

People could suggest articles, and vote on which one they want to read next. And it's free. And collaborative. And the kind of thing I tried to do with my residents, back when I was a unit chief.

A book club would work, too, but that would involve a purchase.

There are all kinds of online learning resources:

MIT's OpenCourseWare
MIT and Harvard's EdX
The Khan Academy

Why not, The Psychiatry Collaboration?

I'd love for readers to comment on this post. Let me know what kind of lifelong learning works for you. Where do you go to stay current? Would you participate in a free online journal club?

How about this article:

A Rating Scale for Depression, by Max Hamilton
J. Neurol. Neurosurg. Psychiat., 1960, 23, 56.

I found the link to it on the BMJ site. I've never read it before, and sure, it's from 1960, but it might be interesting and fun to read about the early development of the HAM-D.

Tracking CME

I just bought an app to track my CME on my iphone. It's called, CMEasy, and it cost me $1.99. I know people complain about the cost of apps, but honestly, most of the apps I use are free, and if the occasional one costs a dollar or two, really, no biggee. It's less than a cappuccino.

Up til now, I've been saving my certificates on my computer, and on Google Docs. It's a bit of a pain, uploading and moving things to the right place.

I looked around online for a tracker, but most are associated with sites to earn CME. The Epocrates CME app lets you track external credit, but it has all these drop down menus, and I know I won't bother.

The CMEasy app is nice. It lets you create templates for frequently used sources of CME. So, for example, I have a "Carlat" template, with a standard 1.0 CME credits. You can change the number of credits, if appropriate. It gives you a place to jot down notes, and it records the date.

It keeps a pie chart of all your CME by category type. You can create your own categories, including AMA Category 1 or 2, etc. The one real drawback is that it doesn't keep a copy of any certificates, just your word on what you've earned. But I figure as long as I have a list of where I earned the CME, I can always find the certificate. All-in-all, it's simple and intuitive, which means I'll probably use it.

CME-Where to Find It, Continued

Medpage Today

This is free CME in little bite sized pieces of news, worth 1/4 point each. It's quick, it's easy, it takes maybe 5 minutes, including the evaluation. It's jointly sponsored by The Perelman School of Medicine at the University of Pennsylvania, and by Medpage Today.

It has a nice little app that's very user friendly, but I have trouble finding the CME section on the webpage. So I recommend sticking with the app for the actual CME. The website has a good CME tracker, though.

Quantia

This is the real sell-out site. Not only do you get 1/4 point of CME, you can also earn "Q-Points". These are points you get for participating in some of their activities, and they can be redeemed as Amazon points.

Drawbacks include the obvious sell-out factor, and the fact that they don't specifically have a Psychiatry section. But there are Psychiatry-relevant pieces of CME in the Pain and General Medicine sections.

When I first found this site, I was a little hesitant to be that blatantly mercenary. But then I realized that I had paid the APA $300 for the answers to their CME questions, which basically amounts to paying for CME, without actually learning anything.

And then I did this activity on Quantia which was a power point given by a Fellow in Addiction Medicine. It was about the labs hospitals use to measure substances of abuse, and it was interesting, extremely well-presented, useful, and completely free of financial bias. When was the last time you saw an ad-free issue of The Green Journal?

Quantia has a nice iphone app, although the activities are easier to do online. Their site is pretty good, and the power points are interactive-a nice touch.

Epocrates

They have CME included in their app. There's not a lot of Psychiatry available, and what there is is case-based. But you can earn a couple points from them, and the app is worth having as a drug reference, in any case. This is another one where I couldn't find the CME on the web, but it's easily accessible from the app.

CME-Where to Find It

In my last post, I threw down the gauntlet with a bunch of questions about CME that I need answered. The first one I'm going to address is where to get CME. These are the resources I've found:

Psychiatrist.com

This is the site for The Journal of Clinical Psychiatry. I've always thought of this as a throwaway journal. I'm not even sure what list I'm on that allows me to receive copies of it. But the link takes you to a page that includes JCP, as well as The CME Institute, and some Neuro sites. The CME Institute is pay dirt. You need an account at psychiatrist.com, and then you can link to a plethora of material, all with free CME. And really not bad, if somewhat commercially biased. It even includes some self-assessment activities (more on what that means in a later post).

The one glitch I've found is that if you just click on the link that takes you directly to CMEinstitute.com, It's hard to find the extensive list of CME activities. It's much easier to get to the CME from the psychiatrist.com homepage, by clicking on the little "All CME Activities" link under CME Institute.

Or you can just use my link: All CME Activities. Also, a nice addition would be an iphone/ipad app.

The Carlat Report

This is a paid monthly newsletter that's worth paying for. First of all, they don't take money form Big Pharma, or any other commercial source. This means no ads, and little, if any commercial bias.

You get 12 CME category 1 credits per year, all taken online, although the questions are included in the hard copy. They also offer pretests, a relatively recent addition, in order to satisfy self assessment criteria. You take the pretest, which doesn't count, to see how much you know before you read the newsletter. Then you get your pretest score, along with the correct answers. Ostensibly, you go on at that point to read the report, and finally take the post-test, which is the same as the pretest, and for which you receive credit. In other words, you don't need to actually read the report to get all the answers right, which is annoying, but part of the deal with the genius of self-assessment.

That said, it's worth reading, anyway. The articles are well written, well-researched, and informative, and at the end of each-this is my favorite part-they give you the "TCPR take", their opinion of what the bottom line is. So you can cut through the nonsense and try to make good clinical decisions.

The Carlat Psychotherapy Report

New in 2012, this is a spin-off the the Carlat Report. It gives you 10 CME credits per year, all in topics involving psychotherapy. It costs $89 per year, with a $59 introductory rate. It employs the same format and standards as the original Report, and if therapy is a large percentage of your practice, as it is in mine, it's worth it.

CME-The Questions

First up on my agenda is to make it easy for myself to earn CME, preferably for free. As a member of the APA, I naively thought I could earn free CME from the Green Journal just because I have a subscription. Not so. You have to pay each month, if you want to earn the 1 point of CME they offer.

Last year, I subscribed to Focus, the APA's CME journal that allows you, POTENTIALLY, to earn your 50 points of CME. This cost me $300 and didn't prove that useful. So this year, I need a better way.

Here are some questions I need answered:

1. How many points of CME do I need each year, in order to meet requirements for Board recertification?

2. What kind of CME? Is it all category 1, or am I allowed some category 2? And what are these categories?

3.Where do I find the CME, if I don't want to attend grand rounds at the hospital I'm affiliated with?

4. What is the real educational value of the various CME I can get?

5. What qualifies as self-assessment and performance in practice, and how do I get these?

6. How can I keep track of my CME, if I get it from multiple places?

To be continued...