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