Opioid Training Requirement

New York State recently decided that in order to address the problem of opioid abuse, all physicians (and non-physician prescribers) with a DEA number need to be trained in pain management, palliative care, and addiction. By July 1st of this year. I found out about it in the middle of March.

And it needs to be repeated once every 3 years.

The required course work covers the following eight topics:

(1)        NYS and federal requirements for prescribing controlled substances;
(2)        Pain management;
(3)        Appropriate prescribing;
(4)        Managing acute pain;
(5)        Palliative medicine;
(6)        Prevention, screening and signs of addiction;
(7)        Responses to abuse and addiction; and
(8)        End of life care.


I. Don't. Prescribe. Opioids. Period.

What I'm saying is, this training has no relevance for me, and is another example, aside from MOC, of taking time away from educational or clinical experiences that are useful to me, to do someone else's busywork.

I think whoever came up with this idea is trying to create the impression that something is being done about the opioid problem, without thinking it through. A more reasonable, and respectful approach would have been to say, "If this is relevant to your practice or work setting, then you must get this training. And if you don't have the training and you do prescribe opioids, you're in big trouble."

Here's an indication of just how poorly thought out this program was:

Providers will be required to attest to completion of the required course work or training.  The Department of Health has not yet released instructions for submitting an attestation, but has indicated that more information is coming soon.  

As I mentioned, this was back in March. There is now a way to attest, by going to the HCS portal, then "My content" --> "All Applications" --> "N" --> "Narcotic Education Attestation Tracker (NEAT)".  This is where the directions come from.

And for reference, this is the actual announcement.

There are two currently available courses that satisfy the training requirements (that I know of):

The New York Chapter of the American College of Physicians offers a three-hour online course on the required eight topics in conjunction with the Boston University School of Medicine.  This course is available free of charge to all providers.  You can view the course announcement by clicking here.

The Medical Society of the State of New York is also offering three 1-hour online courses covering the required eight topics.  The courses are free to MSSNY members and will be made available to non-members for a fee of $50 per module.

I couldn't figure out how to access this course without paying dues and logging in to the MSSNY site. But why would I want to pay $150 for a course I can take for free elsewhere?


The statute does provide an exemption from the course work or training requirement for DEA registered providers, but it's not clear to me under what circumstances, or how it can be done:


...The DOH may grant an exemption to the required course work or
training to an individual prescriber who clearly demonstrates to the DOH that there is no need to complete such training. Exemptions shall not be based solely upon economic hardship, technological limitations, prescribing volume, practice area, specialty, or board certification.

When I was making my attestation, there was a button you could press to ask for an exemption, but I didn't press it since I wasn't asking for one, so I don't know what happens when you do.

Now about the course. This is an aside, but one thing that pissed me off is that while the course provides CME credit for everyone who takes it, those certified by the ABIM can use it as SA credit, while those certified by the ABPN cannot. If that's not a scam on the ABPN's part, I don't know what is.

The first two modules were completely useless to my practice, although I found the content interesting. They cover how to:

Determine when opioid analgesics are indicated
Assess for opioid misuse risk
Talk to patients about opioid risks and benefits
Monitor and manage patients on long-term opioid therapy

One thing that struck me is that the course seems to be intended mainly for primary care providers, and it's hard to imagine when someone who is responsible for everything involved in primary care would have time to deal with pain management and potential for misuse.

The third module was useless as well as boring. It was basically just someone rattling off NY State laws governing the safe prescribing of opioids, and how to, "Appropriately document communication with patients about health care proxies and advance directives and describe the appropriate use of advance care planning CPT codes."

I dozed off several times. I still managed to pass.

So if the topic is relevant to your practice, or you're looking for some free CME credits, or if neither of these is the case but you have a DEA number in NY State, then by all means, take these classes.

OOOOOOKLAHOMA!

Good news for doctors in Oklahoma, also known as the "Sooner State", "...in reference to the non-Native settlers who staked their claims on the choicest pieces of land prior to the official opening date."

I learned from an email from the National Board of Physicians and Surgeons (NBPAS, See, "Another Board", and "Summing Up 2015"), that in response to pressure from physician groups like NBPAS, the Oklahoma state legislature has passed a bill stating that Maintenance of Certification (MOC) cannot be required as a condition of licensure, reimbursement, employment or admitting privileges. The bill was approved by the governor on April 11, 2016.

The link to the bill is here. You need to click on "SB1148" in the upper left-hand corner to view the actual bill. The relevant language is the following, with an otherwise identical clause included further on for osteopathic doctors:

G.  Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state.  For the purposes of this subsection, "Maintenance of Certification (MOC)" shall mean a continuing education program measuring core competencies in the practice of medicine and surgery and approved by a nationally-recognized accrediting organization.

Go, Oklahoma! And because I'm a little giddy about this small but important victory, I'm including this Sesame Street clip:

Tequila MOC-kingbird

First, sorry about my prolonged absence. I've been writing an article for Carlat, and it's taking up all my time.

Second, sorry about the title. I'm pretty sure I saw a cocktail called, "Tequila Mockingbird" on some restaurant menu, but I can't remember where. And then an MOC topic came up, so.*

Got this email today:

AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY EXPANDS
IMPROVEMENT IN MEDICAL PRACTICE (PIP) OPTIONS FOR DIPLOMATES

February 18, 2016, Buffalo Grove, Illinois --- The American Board of Psychiatry and Neurology, Inc. (ABPN) has expanded the options for diplomates for their one required Improvement in Medical Practice (PIP) activity every three years to include any Clinical Module OR Feedback Module activity listed on the ABPN website.

Effective immediately, this development now gives diplomates more flexibility with the Part IV requirement for their maintenance of board certification.

The ABPN Improvement in Medical Practice Unit is a quality improvement exercise designed to identify and implement areas for improvement based on the review of one’s own patient charts (Clinical Module), involvement in personal or institutional quality improvement activities, or feedback from peers or patients via a questionnaire/survey (Feedback Module).

“These additional options for fulfilling the requirements of MOC Part IV recognize the importance of patient and/or peer feedback to the process of physician quality improvement, and it should also make it easier for many ABPN diplomates to document their quality improvement activities,” said Larry R. Faulkner, MD, ABPN President and CEO.

More details, including full option lists for both the Clinical and Feedback Module activities, are available on the ABPN website.

Reading this evoked a kind of comical fury in me. The ABPN is stooping pretty low, but it just won't bow to the pressure to remove Part IV. In case you've forgotten, and who wouldn't want to, there's lots of controversy about the Part IV Performance in Practice (PIP) modules, which you often need to pay for, and which have not been demonstrated to do anything but raise blood pressure. The American Board of Internal Medicine (ABIM) caved to its protesting diplomates, suspending Part IV until 2018. But the ABPN did not.

If the Board thinks PIP is so valuable, why agree to make it an either/or with a form that any diplomate can fill out five times by herself, asking her friends for their approval and signatures, in exchange for her own?

I checked out the ABPN products list page, and after a click or two, I got this:

The bottom part scrolls to more options, and it's almost this difficult to read. The important column here is, "PIP F", the feedback modules. It took me a little while to find the right one. There were a couple "page not available" dead ends, as well as ones that didn't apply, like the adolescent feedback and patient forms. I've discussed my thoughts about patient feedback forms elsewhere.

The main form you need, if you're willing to be the ABPN's bitch and do this, is the ABPN's Peer Feedback Form (NOT the AACAP's form, which gets you a description of MOC). It gives you a 1-6 Likert scale in six areas:

Patient Care
Medical Knowledge
Interpersonal and Communication Skills
Practice-Based Learning and Improvement
Professionalism
Systems-Based Practice

'Nuff said.

I had already decided to wait to see if the ABPN makes any concessions about Part IV and the meaningless, expensive recertification exam that exists to pay ABPN salaries, to decide if I want to bother re-certifying again, or to fulfill any of the requirements other than CME. I'm taking this concession as a sign that I should keep waiting.



* I just Googled "Tequila Mockingbird", and I got a link to this book:

Maybe I saw it in a bookstore? The drinks have names like, "Last of the Mojitos", "One Hundred Beers of Solitude", and, "The Rye in the Catcher". It looks like fun.

Summing Up 2015

Here we are at the end of the year. A lot has happened in the world of psychiatry in 2015.

Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).

On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.

I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:

Maintenance of Certification

I studied for:
The Montillation of MOC
Percentages

And passed:
Done
There and Back Again
Framed
Signed, Sealed, Delivered
Switching the Labels

my board recertification exam.

And I was certified by the NBPAS, as well:
Another Board

The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money

Although the Part IV Feedback modules are now optional.

And I developed my own Psychoanalytic PIP Module:
Fascinating
Here Goes Nothin'
A Monkey's Uncle

The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.


Affordable Care Act (ACA)

The ACA has kicked in:
Out of Network Benefits in NY

And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA


Psychoanalysis

I terminated my analysis:
Termination
Blessings

And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2


Jeffrey Lieberman

His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.

And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks


Addyi

The FDA approved a drug that could hurt you but can't help you:
They Caved

That was immediately sold for $1Billion:
Addyi-dendum

And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda


Paxil 329

Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:
329


Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.

On to pastures greener.

A Monkey's Uncle

I had a hard time naming this post. Everything I thought of had some kind of expletive in it.

Holy ____! 

____ me dead! 

l'll be ____!


I'm not averse to this kind of language in my speech, but I try to keep it out of my writing unless there's a good reason for it. Like if I'm quoting someone. Or if I'm writing about having witnessed a potted tulip fall from space and say, "Not again!"**

Suffice it to say, I'm surprised. I got a response today from the ABPN about my proposed PIP Clinical Module on the "Suitability for Psychoanalysis". Here it is:

Thank you for submitting an individual PIP for preapproval consideration.

Your PIP Clinical Module on the ‘Suitability for Psychoanalysis’ has been preapproved, provided you use your own patient charts/data for the initial and follow-up reassessment.  The patients that you use for the reassessment can be the same or different patients from the initial assessment.  This module will count for the PIP Unit that you need for your 2016-2018 CMOC block.

Please retain this preapproval in the event of an audit.

Let me know if you have any other questions.


I did have questions, so I responded:

Thank you for your prompt response. I will certainly use my own patient charts and data.

I have 2 questions:

1. Does "preapproved" mean it's approved, or is there something else that has to happen?

2. Are others allowed to use this module for their own patients?

Thank you for your attention to this matter.


I just sent off my response, so I don't know what will come of it. I'm a little worried that it's too good to be true, and I should have left well enough alone and not asked my questions because now they'll change their minds. But I'd like for other people to be able to use the module, and I wasn't sure if, "provided you use your own patient charts/data for the initial and follow-up reassessment," means that for some reason, they thought I would use someone else's patients' data, or if it's only approved for my use. Maybe that's what "preapproved" means.

So for now, Odds Bodikens!, Zounds! Holy Mackerel! I'll eat my hat!, and I'm a Mongoose! And remember, if I can make up a PIP Module that gets "preapproved", anyone can.

Addendum: 

Wow! While I was previewing this post, a response from ABPN came in:

1.        Preapproval means that your PIP meets the criteria, although you are still subject to auditing.

2.       Preapprovals are done on an individual basis; but, yes, if you’d like to share your outline with colleagues, they could submit it for preapproval as well.


So I guess anyone can use it, provided he or she submits it for preapproval. Here's a link to it in pdf form. I hope it's helpful.

Addendum #2: If you happened to download the pdf before 11.17.15 4:55pm Eastern time, please disregard it and use the currently linked form, which includes the practice guideline source.

**“Curiously enough, the only thing that went through the mind of the bowl of petunias as it fell was Oh no, not again. Many people have speculated that if we knew exactly why the bowl of petunias had thought that we would know a lot more about the nature of the Universe than we do now.”― Douglas Adams, The Hitchhiker's Guide to the Galaxy

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.

Fascinating!

The idea for this post is based on a post by Jim Amos, The Practical Psychosomaticist, entitled, Getting Small Again About MOC. At least, that's how it started.

Dr. Amos wrote to someone at the ABPN to find out if instead of doing PIP modules, often at substantial cost, a diplomate's use of PubMed could be tracked by the Board. He was informed that PubMed use was not an option as a PIP alternative, but that, "You have the option of seeking individual preapproval for either one (PIP) that you develop, or one that you may already be doing as a QI project in your hospital/institution."

And he was given a link to the Individual Part IV Improvement in Medical Practice Approval Request.

So I started to think about the possibility of designing a PIP for the practice of Psychoanalysis.

This is how it works:

Clinical Module: A clinical module requires that you do a chart review of at least five patients in a specific category, (for e.g., diagnosis or type of treatment, treatment setting). You must then compare data from the five patient cases, utilizing a minimum of four quality measures, with a standard specialty practice guideline. Based on the results of the review, develop a plan of improvement, carry out the plan, and in no more than two years, do a second chart review utilizing the same guideline to see if improvement has taken place. The charts may be the same or different patients but must be in the same category utilizing the same guideline and quality measures. (boldface mine)

Where do I get a standard specialty practice guideline for Psychoanalysis? I started looking online, and that's when the idea for this post changed. Because I found an Evidence Based Guideline for Psychoanalysis from BlueCross BlueShield of North Carolina.

This is a short but fascinating document. How to explain?

It has a nice, brief description of Psychoanalysis as a "procedure or service". A bit about theory, how it can be helpful, the logistics, what kind of patient is suitable for analysis, and how analysts are trained. Really quite nice.

Then it goes on to describe the "Evidence Based Guideline", and completely contradicts everything in the preceding section.

For example, in the first section, there's this paragraph:

The person best suited for psychoanalysis is one who is generally successful in most aspects of his/her life but is still unhappy. Psychoanalytic therapy is said to be beneficial for those with troubled relationships, poor self-esteem, anxiety, chronic irritability, unresolved grief, phobias, and many other conditions where they want to understand themselves and see how their own thoughts and behaviors contribute to their difficulties. Psychoanalysis is thought to promote self discovery, personal growth and development. (boldface mine)

But then, in the guideline section, it states, "Psychoanalysis is not recommended for...treatment focused on increasing self awareness, self discovery, or personal growth."

I get that they're saying self-discovery shouldn't be the purpose of analysis-not an analysis they're paying for, anyway, but really, at least change the language so it's not identical.

The guidelines are antithetical to everything an analysis is supposed to be. The "A" criteria are:

Psychoanalysis (PSA) may be appropriate if nothing else has worked.

The patient needs some kind of problem that corresponds to a diagnosis
AND
The patient has distress in work/school/social
OR
an ongoing disorder that requires "behavioral assessment to maintain symptom relief and/or function"
OR
"additional treatment sessions are needed (documented by clinical evidence) to prepare for termination of therapy consisting of a clear treatment plan with well defined goals, methods and time frames to support discharge from therapy"
AND
The patient doesn't need to be in a locked unit.

"Well defined goals, methods and time frames" in an open ended, free associative psychoanalysis. How does that work?

The "B" criteria are even worse. I'm just gonna cut and paste and highlight the phrases that particularly annoy me:

B) All of the following criteria are met;
1. There is documentation of a mental disorder diagnosis, AND

2. There is a medically necessary and documented treatment plan or updated plan
individualized for the patient with at least one of the following outcomes;

a) focuses on alleviating the patient’s distress and/or dysfunction in a timely manner, or
b) pursues achieving maintenance goals for ongoing conditions, or
c) focuses on discharge from therapy, AND

3. The individualized treatment plan includes all of the following:

a) the status of the patient’s dysfunctions being treated and documentation shows
progression toward the treatment goals, and
b) the current treatment is focused on each psychiatric symptom, and
c) treatment framework, and
d) modality of treatment, and
e) frequency, and
f) estimated length of treatment, and
g) the status of the involved family or friends in support of the patient, and
h) the status of any necessary community resources, and
i) an alternative plan if the patient does not make sufficient progress in the time frame
specified, AND

4. The treatment must be rendered by a "certified psychoanalyst" from a nationally recognized
institute for psychoanalysis.

And now my corresponding comments:

How do you define "medical necessity" for PSA?

PSA often increases the patient's distress in the short term

Timely?

Focus on discharge: You better hurry up and change a lifetime's worth of patterns so we can terminate!

Status of dysfunctions?

Symptom focus? That's not PSA.

What do they mean by "treatment framework"?

The modality is PSA, duh!

You don't do family meetings in adult PSA

By their own description, PSA is appropriate for people who are generally successful. What kind of community resources are they talking about?

Define "progress"!


It sounds to me like they just took guidelines for some other kind of psychotherapy and pasted them in.

Now the worst part. The evidence.

There are 4 reference sources listed. The first is:

Dewey R. (2007). Psychoanalysis. Retrieved 7/10/2008 fromhttp://www.intropsych.com/ch13_therapies/psychoanalysis.html

This seems to be some kind of online Psychology Intro text. Psychoanalysis takes up one page. One very short page. It includes no information that would constitute a guideline, evidence based or otherwise. It describes what I consider a misinformed and outdated notion of PSA.

The second source is the "About Psychoanalysis" page on the website of the North Carolina Psychoanalytic Society. It's just a brief blurb about psychoanalysis, the couch, frequency of meeting, and the like. Nothing here in the way of guidelines.

The third source is the American Psychoanalytic Association's Standards for Education and Training in Psychoanalysis. This is a 23 page document that describes requirements for training in PSA. Like, who is eligible to be a candidate. How many case write-ups do they need to complete. It has nothing to do with guidelines for practicing PSA.

The last is the DSM-5. We'll ignore that, since it's just about diagnoses.

What we have is a completely bogus "guideline" that has no evidence base whatsoever, nothing to do with PSA, and everything to do with not wanting to cover the cost of an analysis. If you're an insurance company and you cover mental health, then you really can't afford the cost of an analysis for everyone who would benefit from one. And I guess they can't just outright state that they won't cover PSA because it's too expensive. I get it.

And in case you were wondering, this is not an out-of-date document. It was written in 2008, and reviewed in 2010, 2011, 2012, and last updated a year ago, when some (unspecified) references were removed, and others added. No changes were ever made to the guideline statement other than wording. It's up for another review this month.

I wonder if the ABPN would accept it as part of a PIP module.

Actually, the title of this post is wrong. Mr. Spock says, "Fascinating," when there's something interesting that he doesn't understand. If he does understand it, he just says, "Interesting."

Switching the Labels

For no particular reason I can discern, I took my current ABPN Board Certificate off my wall today, and turned it over to see if I could figure out a way to simply replace the little rectangle that states my certification expires at the end of this year.

Certainly this was prompted by not wanting to put up the new certificate, which I wrote about in Signed, Sealed, Delivered. But why today I have no idea.

Anyway, this is what I saw on the back:

Sorry for the crummy iPhone photo-I hope you can read it. The main points are that these are instructions for adding "Future Recertification Labels", and the backing removes easily for the replacement of the label.

I guess I hadn't looked at the back of the thing in quite some time, because I couldn't remember why I thought all I'd have to do when I got recertified was replace the little rectangle.

But this is why. The plan was clearly to have a recertification label every 10 years. NOT, mind you, a big, galumphing new certificate that wags its finger at readers as if to say, "Your doctor had better cough up the annual fee and do those PIP modules, otherwise she'll lose her certification and your care will be compromised and she'll be very, very bad!"

So now, I'm just going to remove the old label, and replace it with a decorative swatch of my choosing.

These are some possibilities:

I'm looking for suggestions, so pipe up with ideas.

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.

Framed

I really thought I was on an extended hiatus from being irked by the American Board of Psychiatry and Neurology. I was all set to wait until I get the bill for the annual fee to be pissed again, but they got to me sooner.

I haven't yet received my new board certificate. When I got my board scores, the package included a certificate shipping form that I could fax to them if I wanted to change my shipping address. It also had a box you could check if you were willing to waive the required signature. I wanted to do this in case no one was home when it was delivered, but the form was incomprehensible, because it wasn't clear if you had to change your address to check that box, or if you should include your current address or leave it blank because you don't have a change of address. I figured anything I did would only make it worse, so I didn't bother with it.

That was bad enough. Today, I get a letter from Jim Henry, Inc, informing me that my certificate is being prepared, and will be mailed to me on June 30, 2015. It also offered me, "A choice of quality frames as described in the enclosed brochure... Just indicate your choice of frame...and return it to us with your remittance no later than May 19, 2015. If no order is received from you by this date, your certificate only will be sent to you unframed at NO CHARGE." (boldface and caps are theirs, not mine).

I am so done with these people. The frames range in price from $70 to $600, with additional costs for special finishes. I already have a framed certificate. The ABPN sent it to me the first time around. It has a little rectangular piece in the lower left hand corner with the expiration date, and that's all that needs to be replaced. But they're sending an entirely new certificate with no expiration date which will need to be framed.

If I bother.

Do I have to speculate about whether the ABPN gets kickbacks on the frames? Honestly, the brochure looks like something from a company that does high school yearbooks. And if you checked out the link to their site, you may have noticed the "pharmaceutical" tab at the top. It links to this page, with the image:

Thousands of dollars in direct payment, board review, and lost patient hours already spent, and now they want me to pay for a crappy frame. Boy they must be broke. How fitting that medical associations and the pharmaceutical industry are grouped together.



In the words of someone very wise, "Sheesh!"

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?

Follow the Money: A One Question Survey

Check out the update on MOC, recently sent out by the ABPN. In particular:

And:

Also:

Finally:

Okay so wudda we got?

You have to attest to your CME, SA, and PIP activities, and pay a fee annually.

And you only need 1 PIP unit.

Also the PIP requirement has been modified.

Finally, the board MAY waive SA requirements.


To me, it sounds like the ABPN is getting desperate. They want you to pay the annual fee, so they make noises about modifications to requirements. But if you pay the fee anyway, why should they make any changes?

And judging by the financial state of the ABIM, I'm guessing the ABPN is not doing so great money-wise. Plus they're obviously worried about losing diplomates to the NBPAS.

I think doctors as a group are a pretty suck-it-up bunch. We're so used to hard work that if you tell us we need to do something for "patient care" or for "regulatory requirements", we just do it. (See my post, The Culture of Medicine and the Art of K'vetching).

But this seems like a good jumping off point for negotiations. They want us to invest $175/year in them, with the promise of a meaningful exam in 10 years. Okay. What are they going to do for us? How about they remove the Part IV requirements, as a sign of good faith, and while they're at it, lay out a plan for how they're going to demonstrate that taking an exam every 10 years improves patient care. And once they've done that, then, maybe, we'll start paying them.

Seriously, what if everyone who goes into the C-MOC program joins together and refuses to pay a dime until they hold up their end of the bargain. Because it is a bargain. It's just a financial deal. They shouldn't get to make money AND screw us over.

So here's my one question survey. Is anyone up for this fight? Let's follow the money and see where it leads:



Create your own user feedback survey

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

An MOC Step?

Email today from the APA:

Dear Colleague:

The APA Board of Trustees is aware of members’ significant concerns over the “Part IV: Improvement in Medical Practice” portion of the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) Program. Therefore, yesterday, the APA Board voted unanimously in support of the following motion:

MOTION:

• The American Psychiatric Association (APA) Board of Trustees, acting on the recommendation of the Assembly Executive Committee, and representing over 36,000 psychiatrists, supports the elimination of Part IV of Maintenance of Certification (MOC).
• Therefore, the Board of Trustees recommends to the American Board of Psychiatry and Neurology (ABPN) that they lobby and advocate the American Board of Medical Specialties (ABMS) to eliminate Part IV of the MOC,
• that the APA reaffirm its commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice, and
• that the APA will establish a joint Board and Assembly Work Group with the charge to evaluate the broad issue of maintenance of certification for psychiatry and its relationship to maintenance of state licensure and other accrediting bodies. The goal of the work group is to return timely reports to the Board and Assembly including recommendations, if appropriate, for any positions the APA should take regarding any and all parts of MOC.

APA CEO and Medical Director Saul Levin, MD, MPA, and I have sent a letter to the ABPN, which is clear about the confusing and cumbersome nature of the program and the substantial concern which our membership and the Board of Trustees has regarding the evidence base of Part IV of MOC. At the same time, the Board further reaffirmed the APA’s “commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice.” I look forward to being able to share the Board-Assembly Work Group’s findings in the near future.

We highly value our collaborative relationship with the ABPN and will work with them, other groups and, of course, our members to resolve the widespread concern about these issues.

Sincerely,

Paul Summergrad, MD
President

American Psychiatric Association

To remind people, Step IV consists of the Performance In Practice (PIP) modules, the 5 peer reviews, and the 5 patient reviews, which I wrote and complained about in one of my earliest posts, Alphabet Soup, back in November of 2012. Currently, we are no longer required to do both the peer and patient reviews (and I consider these last to be a boundary violation), but rather, one or the other, or a couple of other possibilities which I was going to cut and paste from the ABPN page, but for some reason the chart won't load on my computer. I think two of them are a 360 degree review and 5 resident reviews.

So now, the APA has FINALLY jumped on the bandwagon, when they see that there are other certifying boards (like the National Board of Physicians and Surgeons, see my post, Another Board) out there that don't require crazy PIP modules that have no evidence to support their utility. The PIP modules are a money-maker for the APA, or at least they have been, so I assume the motivation for getting rid of them as a requirement comes from the fact that the APA is losing membership and money, and may lose more if its members recall that the APA did absolutely nothing to prevent the institution of these requirements, to begin with. Only now are they establishing a Board and Assembly Work Group.

I guess I'll take what I can get from the APA, and maybe this is better than nothing. But they've done poorly by their constituency with regard to MOC in the past, and I don't see any reason to assume they'll do any better in the future, unless supporting their constituency happens to coincide with their own interests, whoever "they" are.

Done.

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.

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