Maintenance of Certification

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RESOURCES

Few recent issues have affected us as a profession as much as Maintenance of Certification (MOC). Although the details are complicated, the basic rationale is simple: psychiatrists need to show that once their formal training is over, they are continuing to practice lifelong learning. The adage of the wise old doctor who improves with experience is not true: doctors’ skills tend to deteriorate after their formal training is over if they do not challenge themselves to keep up with the latest developments in their field.¹ Prior to formal MOC, most states required some evidence that we were keeping up with our field; this was usually achieved through the accumulation of Continued Medical Education (CME) credits. However, we all know that this can range from very active participation in excellent courses to simply showing up, signing in, and heading out to the golf course.

Considerable evidence suggests that CME alone is ineffective at achieving its goal of keeping physicians up to date in their specialties.² As a profession, we are a very motivated group, and we would like to think that the desire to learn and grow, to remain on the cutting edge of our field is motivation enough to remain lifelong learners in our field. Nevertheless, we are only human, and with the multiple demands on our time, voluntary educational efforts tend to make way for the more pressing exigencies life throws at us.

Why is MOC so important? The answer is simple: because our patients deserve this. When I see my primary care doctor to discuss my health issues, I assume that she is aware of the latest guidelines and standards as well as promising research. I routinely bring up studies I have read and am usually reassured that she’s read them as well and has an informed opinion as to the findings. This should not be an unusual occurrence; it is what I expect of my doctor. Surely, my patients should expect the same of me.

That lifelong learning is important to professional development is inarguable, but the devil is in the details. How can one demonstrate that he or she is keeping up with latest developments in the field? The American Board of Psychiatry and Neurology (ABPN) has identified 4 components that must be demonstrated to remain board certified:

1. Professional standing

2. Lifelong learning (CME) and self-assessment

3. Assessment of knowledge, judgment, and skills

4. Improvement in medical practice, ie, performance in practice (PIP)

The first and third components are not new: professional standing is demonstrated by holding an active and unrestricted license to practice medicine, and cognitive expertise is demonstrated by passing an ABPN board examination; these have been longtime requirements for board certification. The second component is an elaboration of the previous expectation that physicians complete a minimum number of CME activities: diplomates are expected to complete an average of 30 specialty or subspecialty Category 1 CME credits and an average of 8 self-assessment CMEs per year, averaged over 3 years. The purpose of self-assessment is to alert psychiatrists to potential knowledge deficits in order to direct their study at a CME activity. The final component, improvement in medical practice or PIP, is a type of quality assurance in which physicians must demonstrate that they are assessing their own practice through either a Clinical Module, entailing a quality improvement exercise such as a chart review, or a Feedback Module in which the psychiatrist collects data from peers or patients.

There have been various criticisms of the process. From a broad perspective, there remains a great diversity and variance in defining what components should be used to constitute MOC programs.³ However, it is difficult to dispute the basic principles underlying this effort: a doctor’s education does not end with residency training and if we as a profession do not develop a credible system for monitoring continued competence in our specialty, other groups will do it for us. Many other specialties have ongoing systems in place, some for a long while, so, in a sense, psychiatry is simply playing catch up.

In response to criticisms, the ABPN has made several changes to the requirements in the past several years, including lessening the overall requirements and allowing for activities that one may already be performing as part of one’s professional role. For example, most individuals working in a hospital system are expected to participate in quality improvement efforts, and many of these could potentially count as PIP as well. The ABPN has approved a number of existing products and quality improvement programs (see Resources).

Even with this greater flexibility in the requirements, this system creates some burdens, both in complying with these requirements and in record keeping. A number of organizations are attempting to help with this. For example, the ABPN is maintaining a Physician Folio site to help with record keeping, and the American Psychiatric Association (APA) lists resources that address the various aspects of MOC. A number of other subspecialty organizations have developed programs to meet some or all of the MOC requirements. For example, the Academy of Psychosomatic Medicine offers Self-Assessment credit as part of their annual meeting activities; a number of other organizations offer similar activities.

For those who feel that they are not keeping up with the requirement, what should they do? The most important thing is not to avoid this. The ABPN conducts random audits of activities, and before taking a recertification exam, you will be required to attest to your MOC activities. So it is best to keep up to date. If you have not done this already, the first thing you should do is register for the ABPN Physician Folio, which is an excellent way to keep track of your MOC activities and to be aware of what your outstanding requirements are.

Finally, if you are one of the many dissatisfied with the MOC process, I encourage you to become active at an organizational level, either at your state or national level. Although MOC is not likely to go away, there is certainly room for improvement, and my experience has been that the ABPN is open and interested in feedback as to how to make the system better. Ultimately, the purpose of this is to help us be well-informed psychiatrists for our patients, and the more the system helps us achieve that, the more we will see it as an important part of our professional development.

RESOURCES

• Details of the ABPN’s MOC program: www.abpn.com

• ABPN existing products and quality improvement programs: https://www.abpn.com/maintain-certification/abpn-approved-products-list/

• ABPN Physician Folio site: https://application.abpn.com/webclient/folios.aspx

• ABPN MOC resources: http://www.abpn.com/moc_products.asp

• APA MOC resources: https://www.psychiatry.org/psychiatrists/ education/certification-and-licensure

• The Academy of Psychosomatic Medicine: APM.org.

Disclosures:

Dr. Boland is an Associate Professor at Harvard Medical School and the Vice Chair for Education at the Brigham and Women’s Hospital Department of Psychiatry in Boston. He is also the President of the Academy of Psychosomatic Medicine.

The author reports no conflicts of interest concerning the subject matter of this article.

References:

Acknowledgments-I am grateful to Amanda Bishop and Patti Vondrak at the ABPN for reviewing the article. Their contribution was limited to reviewing the correctness of content related to the ABPN MOC requirements. I am not affiliated with the ABPN; the opinions stated in the article are my own as are any remaining errors.

1. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260-273.

2. Nissen SE. Reforming the continuing medical education system. JAMA. 2015;313:1813-1814.

3. Horsley T, Lockyer J, Cogo E, et al. National programmes for validating physician competence and fitness for practice: a scoping review. BMJ Open. 2016;6:e010368.