Board Certification: Two Perspectives

Dr Sidney Weissman made some interesting observations in his December 2010 commentary regarding the American Board of Psychiatry and Neurology’s (ABPN) Maintenance of Certification (MOC) program.¹ The MOC program is a work in progress and we welcome constructive feedback about how it might be improved. However, we would like to address several of Dr Weissman’s misperceptions regarding the goals and requirements of the ABPN MOC program.

By way of background, the American Board of Medical Specialties (ABMS) comprises 24 Member Boards-one of which is the ABPN-that are committed to the ABMS MOC® program. Each Member Board develops its own program on the basis of the needs of its specialty and subspecialties while adhering to the standards established by consensus of all the Member Boards. In devising this program, the ABPN collaborates with its affiliated professional organizations, including the American Psychiatric Association (APA), to encourage the development of a variety of self-assessment, continuing medical education, and performance improvement modules that physicians can use to compare their clinical practices with standards of care (eg, practice guidelines).

Dr Weissman states that “MOC is meant to ensure that diplomates maintain the competency they had when they graduated from residency.” In fact, a primary goal of the ABMS MOC program is lifelong learning, and the 4-part process was developed to encourage continuous improvement and expansion of competencies beyond what was required for graduation from residency. Diplomates are expected to not only possess the up-to-date competencies to provide quality patient care but also demonstrate that they do so with their own patients.

Regarding the ABPN MOC Part IV requirements for patient and peer feedback, the program requires board-certified physicians to seek regular input from patients and peers about the manner in which they relate and how they might improve their clinical practice. This is entirely different from requiring that the practitioner’s work be reviewed, as Dr Weissman maintains. The ABPN Web site (www.abpn.com) contains straightforward model forms for patient and peer feedback that physicians might use to meet this requirement. Physicians are asked to obtain feedback from 30 patients and 30 peers over the course of 10 years. Furthermore, physicians themselves select the peers and patients to complete these surveys, collect and analyze the feedback, and decide what structural or process changes, if any, they might want to make to improve the quality of care they provide to their patients.

The MOC program is a complex process . . . and a work inprogress . . .

Much of the experience to date suggests that psychiatric patients are very willing and able to provide their opinions about the care they receive. There is also growing sentiment about the importance of teamwork and collaboration to the delivery of quality patient care and that professional peers might actually be in the best position to provide physicians with constructive criticism and recommendations for improvement, especially in the humanistic aspects of their performance. In our current era of patient advocacy, patient-centered care, and transparency, it seems likely that pressures will only increase on physicians to consider the perspectives of patients themselves when they deliver clinical services. It would indeed be unfortunate and ironic for the medical specialty that justly takes pride in its special emphasis on the importance of the physician-patient relationship to attempt to separate itself from the rest of medicine in this regard and to deny its patients the opportunity to provide input into their care.

While Dr Weissman’s concerns about “issues of transference” are certainly relevant, it is also true that transference issues are part of all aspects of clinical practice. It remains to be seen whether patient surveys will provoke anything special in this regard.

As Dr Weissman notes, quality improvement programs are hardly unique and already exist at many psychiatric facilities. The ABMS and its Member Boards-including the ABPN-are concerned about redundancy and wish to reduce the burden on physicians. Therefore, we are working toward synergies when these programs exist.

For instance, several of the ABMS Member Boards are involved with a pilot project with the Mayo Clinic that provides physician MOC Part IV credit for their meaningful participation in quality improvement activities at the Clinic. In addition, the ABPN and other Member Boards are considering other ways in which they might recognize the current quality improvement activities of diplomates. When programs do not exist, however, it is incumbent on the Member Boards to make sure that resources are available to diplomates so that they can readily fulfill the requirements for the MOC program.

The ABMS, the ABPN, and all the Member Boards have made great strides during the past decade to implement increasingly rigorous standards of care while also providing health care institutions, insurers, and consumers with the information they need to evaluate the commitment to quality of their physicians within a given specialty. We concur that the various Member Boards’ MOC programs must continually evolve to provide tools for meaningful continuous professional development.

The ABPN recognizes that its MOC program is a complex process and a work in progress and encourages debate about how the elements of its MOC program might be improved to make them more relevant and less burdensome. The ultimate challenge for the ABPN is to design its MOC program in a manner that is credible enough to the public and external organizations so as to be of value to its diplomates, yet convenient enough so that they will choose to participate in it. That is not an easy balance to achieve, and it will only be possible with the help and input of informed diplomates.

Kevin B. Weiss, MD, President and CEO
American Board of Medical Specialties

Larry R. Faulkner, MD, President and CEO
American Board of Psychiatry and Neurology

Reference

1. Weissman S. Does maintenance of certification ensure maintenance of competency? Psychiatr Times.2010;27(12):17.

Dr Weissman Responds

I am delighted to have this opportunity to respond. Drs Weiss and Faulkner assert that I have misperceived or misinterpreted a number of the positions or policies of the ABMS MOC and the ABPN MOC. A careful reading of my comments will confirm that no misinterpretation occurred. Rather, Drs Weiss and Faulkner present an interesting interpretation of ABMS MOC policy and history.

A brief review of the ABMS Mission Statement (Article II of the ABMS Bylaws) is helpful.

The intent of the certification of physicians is to provide assurance to the public that a physician specialist certified by a Member Board of ABMS has successfully completed an approved education program and an evaluation process, which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.

In the 1990s, the ABMS required all of its Member Boards to develop a recertification process for all new diplomates and to put an end to the process of lifetime certificates. It did so to meet the demands of society and to effectively enforce its mission statement. Board certification in this new model would last 10 years, and every 10 years diplomates would need to be recertified.

Boards were required to develop processes to affirm the ongoing knowledge base of their diplomates. Boards opted to use either proctored paper and pencil type examinations or take-home examinations for this recertification purpose. Over time, take-home examinations were deemed inadequate and proctored examinations were required to assess the knowledge of the diplomates of all Boards who were taking recertification examinations. The recertification process evolved into MOC.

We all understand that on graduation from residency and the initial successful passing of the Board Certification Examination, a new diplomate has the broadest, most up-to-date knowledge of his or her field. The challenge for every clinician is to maintain that knowledge base throughout clinical practice and to ensure the continued evolution of clinical skills. It was thought that recertification every 10 years did not adequately assess the diplomate’s knowledge base, nor did it address the specific knowledge essential for a diplomate’s practice. Restated in terms of the ABMS mission, it did not adequately inform the public as to the ongoing competency of the practitioner and as such did not meet the requirements of the ABMS mission.

The MOC program was designed to strengthen the earlier recertification process. It focused on lifelong learning as an essential professional requirement of every practicing physician. The 4-part process Drs Weiss and Faulkner allude to is designed to facilitate and inform the physician’s lifelong learning process. In theory, the process ensures that through-out the physician’s practice life, his knowledge base is as current and relevant as when he graduated from residency.

The process includes an external review of the physician’s functioning by peers and patients. This aids the practitioner’s self-assessment. The required external review of physician activity by patients and peers in many ways parallels the process now in place in residency training. The clinical work of residents is observed and reported on by physician supervisors, patients, and others to the resident’s training director. The training director is responsible for both grading resident performance and providing relevant feedback to the trainee. An implicit question is whether Boards will someday use such feedback to grade the performance of a practitioner. This possibility raises further questions as to the reliability of such data.

Drs Weiss and Faulkner assert that I err in conceptualizing the assessment of practitioner performance noted above as reviews of functioning. They contend that the ABMS requirement for feedback of a physician’s performance by 30 patients and 30 peers over 10 years is not a review of a practitioner’s work, it is rather “entirely different from requiring the practitioner’s work be reviewed.” The practitioner receives feedback from patients and peers. The feedback from these 2 groups is based on a review of their interactions with the practitioner, which are guided by the evaluation tools they use. The value of the feedback is determined by the skill of the evaluator and the instrument used.

As we examine this process, we might ask why feedback from 30 patients and 30 peers over 10 years? Why not 40 or 100? The unique nature and structure of a practice determines how many patients or peers need to comment to obtain useful data. An arbitrary number is not adequate and will not provide useful information. Effective feedback to practitioners requires that statistically appropriate numbers of patients and peers are used. Furthermore, the feedback must be guided by effective evaluation tools. If both criteria are not in place, the feedback process may not be reliable or valid and will not aid the practitioner’s self-assessment.

Drs Weiss and Faulkner imply that I am opposed to gathering data from psychiatric patients because of transference issues and argue that I appear to support separating psychiatry from the rest of medicine. Nothing can be further from the truth. In many psychiatric practices, issues of transference may make obtaining meaningful data from patients difficult. This reality does not separate us from the rest of medicine but highlights how we must be clear on the strengths and limitations of collecting patient-generated data in all medical practices. This reality further informs us of the need to develop effective tools for gathering this information. Psychiatrists can lead the development of these essential tools because understanding the physician-patient relationship is central to much of our work.

Drs Weiss and Faulkner also imply that the APA has had a key role in the development of ABPN policies. The APA has worked with the ABPN in developing a number of educational programs to meet the ABPN’s new requirements. But it has not had a truly collaborative role in developing ABPN policy. During my 6 years of service as a trustee on the APA Board of Trustees, we did not affirm any actions of the ABPN.

Maintaining the competency of our nation’s physicians is a critical element in the delivery of health care. We have made a number of significant strides in the development of educational models to meet these goals. But we do not have definitive answers as to what does and does not work. Lifetime certification of physician specialists lasted for 8 decades. Recertification as a model to accomplish this goal lasted but a decade. In 10 more years, MOC may also be replaced by a new, still undefined, construct. We must not allow the current model of MOC to either be or become a rigid set of requirements, but must use it as a guide to the future.

Society has given the medical profession the critical role of monitoring and ensuring the competence of our nation’s physicians. The ABMS, in its mission statement, acknowledges this responsibility to the public. I hope that Drs Weiss and Faulkner share this view of the responsibilities of the ABMS.

Sidney Weissman, MD
Professor of Clinical Psychiatry
Department of Psychiatry
Feinberg School of Medicine
Northwestern University, Chicago