The Maintenance of Certification Exam as Fetish

The mission of the Maintenance of Certification (MOC) Program of the American Board of Psychiatry and Neurology (ABPN) is to promote “the highest evidence-based guidelines and standards to ensure excellence in all areas of care and practice . . .” Far from succeeding, I am of the opinion that the program does the exact opposite. We have come to a moment of truth in psychiatry, and we are all going to fail. By which I mean pass.

When I took the 200-question exam, this year, I was suspicious that there were no questions about Xanax. How does one measure “excellence in all areas of care and practice” and not ask about the most commonly prescribed medication in psychiatry? Meanwhile, there were several questions about pimozide, which in my experience is prescribed exclusively by psychiatrists who want to brag about prescribing it. I was repeatedly assessed on my competence in dialectical behavioral therapy, but was not asked anything about Supplemental Security Income. A retort might be that SSI has nothing to do with psychiatry-but then why is so much of my time spent on it? The only thing I spend more time on is Xanax.

The insidious problem with the exam was not the content. The usual complaint of “Why do we need to know about pimozide?” should be replaced with the question, “What happens if I fail?” The answer is, nothing. There are no consequences at all. First, 99% of the applicants pass (do the other 1% oversleep?) Second, even if you do fail, you can take it as many times as you feel it’s worth the $1500. Third: there were a thousand easy ways to cheat-I could have “Godfathered” an iPad to the back of a toilet or met with a confederate at the Starbucks across the street. There is more security at a pregnancy test, which made me wonder if how easy it was to cheat was part of the process. The retort is that doctors are expected to behave honorably, but the honorable ones were going to pass anyway. Those in danger of failing-the very people the test should detect-would be most tempted to cheat. Doesn’t the ease of cheating render the test unreliable?

If the test is unreliable and 99% pass, why have a test at all?

The point of the test, then, isn’t to measure competence, but to convey the impression that competence was measured. The point of the test is to say that a test was given-and nothing else.

The question is, to whom are we saying this? It is as if psychiatry was in denial about its ordinary reality and was trying to convey a different identity through the test itself. A psychiatry where there are right and wrong answers, where pimozide matters.

I know: the questions are reviewed for validity; that the test itself “incentivizes” learning; not everyone prescribes Xanax. This misses the point: a flawed system isn’t better than no system at all, it is worse than no system at all, because at least with no system we are forced to be accountable to ourselves for our education. “But not everyone will be so dedicated.” But now those same people get an official blessing of their ignorance. Who doesn’t walk out of this ridiculously meaningless exam not feeling accomplished, current? And who would dare to criticize the exam that warmed his ego?

The board also requires a meaningless number of CME credits, but these are an even worse affront to learning. The only thing that CMEs guarantee is that money was spent on them, which is even sillier than it sounds since I could go to a number of websites that offer instant and unlimited free CMEs, as I skip the long text and just take the post-test . . . which I can take as many times as I want.

The retort is that the system requires a certain level of honor; but if you’re trusting test-takers to be honest in revealing what they know, why not simply trust that they know it? The CME exists to say that there is CME; the CME exists to say there is oversight.

What is truly dangerous about CME isn’t the enormous amount of money spent but that it subverts its own purpose. Like the sale of indulgences during the Middle Ages, CME prevents actual education so that it can pretend that it explicitly monitors it. If you have a minute to spend on your “education,” the system pushes you towards CME. “Why not do both?” Who can do both? There are only 24 hours in a day-I’ve counted them. In other words, the system doesn’t just fail, it fails on purpose.

Last year there was a large cheating scandal at Harvard. Over 100 students were accused of plagiarism, and amidst the usual self-aggrandizing criticisms of the students as entitled or lazy, what no one wondered is why, in an introductory survey course predicated on institutionalized grade inflation and no wrong answers, did the students feel compelled to cheat in a class that they were all going to get A’s in anyway? The terrifying answer is that they weren’t cheating to get the right answer-there was no right answer. They were forced to cheat to concoct the answer the professor wanted-because that’s the system. Meanwhile, what real learning could be done? None. So, why bother with an exam at all? Why not just offer a superior course and abandon the pretense of “objective” grades? The purpose of the test is to say a test was given, to prove to some hypothetically gullible entity that learning occurred. This is why our reflex was to criticize the students, not the system: we are products of that system. To criticize the reliability, let alone validity, of that system would be to open ourselves to scrutiny, to deprive us of a part of our own identity. “Things were a lot more rigorous when I went to college.” No they weren’t. Even if they were, why, when you got to be in charge, did you change the system to this?

Seen this way, these tests are fetishes: a substitute for something missing which saves us from confronting the full impact of its absence. The MOC allows us to believe NOT that we know something but that there IS something to know. There is nothing new to learn; therefore, there must be a test.

The logic of a 10-year MOC is to keep us current, so it’s fair to wonder what has changed in 10 years and what the major advances were. Depakote was loudly considered the default maintenance mood stabilizer despite no supporting evidence, but that fell into disuse at a time oddly coinciding with its patent expiration, which is suspicious, but I’m no epidemiologist. Anyway, it wasn’t on the test. Anything else? A few new medications have come to market, although none of those appeared on the test either. There’s money to be made in the West Coast using giant magnets, (fortunately) also not on the test. Psychoanalysis? The astonishing truth is that psychiatry has made no progress in almost 20 years, let alone 10, a claim no other medical specialty can make, and the truth which cannot be allowed into consciousness. Therefore a test.

When a nurse practitioner asks what about our board exam is difficult, what will you say? Take a minute, it’s important. “Well . . . it has neurology in it.” Note carefully that the psychiatry questions aren’t “harder;” the appeal here is to an expertise in something else, something “more” than psychiatry-and it is this link that symbolizes our status as “experts.” Older psychiatrists will be quick to assert that “clinical judgment” counts for a lot, and I don’t disagree, but it’s probably not testable, and it most certainly wasn’t tested. So $1500 buys you . . . existential support? I hope it was worth it.

What makes the MOC a symptom of a pathology is that although college kids have no idea what they’re up against, that the system is stacked against their education, psychiatry is the very discipline that articulated these defense mechanisms. It should know better; it is supposed to know better. But here we are, spending time and money on cosmetics and pageantry to pretend that we are learning, to pretend that we are being measured, all the while slinging random neurochemicals based on a suspect but billable logic in the hope that something sticks and no one notices. Frantic activity as a defense against impotence. There is a term for that, but you can bet your career it won’t be on the test. Pass.

Disclosures:

Dr Teach is Clinical Director of Stuart-Anne Psychiatric Services in Los Angeles, California. He reports no conflicts of interest concerning the subject matter of this article.