One hundred years after Flexner, the locus and control of medical education has changed. There is a growing recognition and agreement that much of what is taught and learned in medical school and residency is outdated in a handful of years because of the rapid pace at which medical knowledge is expanding. If the time from the day one enters medical school to the day one retires from clinical practice is 50 years, then 80% of this time is spent in unsupervised practice.
The American Board of Medical Specialties (ABMS) has responded to society’s demand for action to ensure the sustained competence of America’s physicians when they are in unsupervised practice and to ensure that clinicians provide quality care.
In 2000, the ABMS altered its recertification process to focus on continuous professional development. This process, which consists of 4 complex components, is referred to as Maintenance of Certification (MOC). Diplomates of all ABMS boards who do not have lifetime certificates must complete this process every 10 years to maintain a board-certified status.
MOC is meant to ensure that diplomates maintain the competency they had when they graduated from residency. The responsibility for developing an MOC program in each specialty that meets the ABMS re-quirements falls on that specialty’s board. In 2006, all ABMS boards approved the essential template for MOC and were given the responsibility to implement an MOC program in their respective specialty. In psychiatry, this responsibility fell on the American Board of Psychiatry and Neurology (ABPN).
As the ABPN phases in its new requirements this year, the full impact and precise requirements are only now being felt and understood by the field.
For the past 100 years, American medicine has endeavored in various fashions to ensure the competence of physicians. A century ago, clinical training focused on medical school education. The Flexner Report of 1910 was created with the goal of improving and sustaining the quality of medical schools and the quality of medical practice.
The essential outline for today’s ABPN program was approved by the ABPN in July 2009. As the ABPN phases in its new requirements this year, however, the full impact and precise requirements are only now being felt and understood by the field.
MOC addresses 2 distinct processes. The first is a cognitive examination, based on issues in clinical practice and the knowledge base of the specialty. The second, which is more complex, is the development of a profile of each practitioner’s clinical practice and of the unique areas of knowledge or clinical activity that he or she must address to maintain competence. It is in the latter domain that controversy exists.
The requirements in the ABPN’s MOC program were developed to respond to the template created by the ABMS. Some feel that these requirements are poorly suited to many psychiatric clinical practice settings. The proposed model appears to have been developed to fit the characteristics of large group medical practices with large patient populations. Even in these practices, the model—which requires that the practitioner’s work be reviewed by 5 colleagues and 5 patients—would appear to make little sense.
First, large group practices generally develop their own quality improvement programs that are far more effective than those proposed in the MOC protocol. Second, asking 5 peers who refer patients to you and to whom you refer patients about your performance seems obviously fraught with the potential for conflicts of interest. As for asking patients their opinion of your care . . . many patient surveys, although designed to elicit information about how patients were treated by their physician, in reality provide information about how they were treated by ancillary staff. These surveys may not provide meaningful data on the actual quality of clinical patient care.
Even if you were to survey patients, why pick 5? A statistically relevant sample would need to be selected for each practice to obtain any kind of useful data.
The problems are even more severe in psychiatric practice. Psychotherapists, for example, have a limited number of patients. Issues of transference, which are relevant to all specialties, are critical in this setting. It is unlikely that a patient in psychotherapy would criticize his therapist. If a patient did offer criticism, how would we know what it meant? Of what use would these comments be—and to whom?
As for comments from peers: how would they know the unique referral base of a given practitioner, and how would they know how the practitioner interacts with patients? How does an inpatient psychiatrist in full-time hospital practice determine which 5 patients to survey, and which doctors to ask?
Psychiatrists who practice in a rural setting have additional problems. Their peers are frequently not psychiatrists. How would nonpsychiatrists assess the practice of someone to whom they refer their patients? I doubt they would be critical, and even if they were . . . what would it mean?
In short: the ABPN has developed a program that—on paper—fulfills its responsibilities to the ABMS and, more importantly, to society. It is less clear whether its program will yield critical information on the clinical practices of psychiatrists. This means that at least in psychiatry, the second element of the MOC process—the enhancement of clinical practice by addressing elements of a practitioner’s work—may be mostly unmet.
The ABMS has assumed the medical profession’s responsibility to society to enhance and ensure high-quality care by physicians throughout their practice life. To accomplish this task, the ABMS must pay heed to the unique practice requirements of every medical specialty. The ABMS must give each board the responsibility and authority to develop protocols for this task, with appropriate review. In turn, psychiatrists must respect and understand the task that the ABMS has undertaken.
Every specialty must develop its own supervised MOC protocols that enable diplomates to monitor and enhance their clinical skills throughout their professional lives. This action is essential if MOC is to ensure maintenance of competency.
