Sidney Weissman, MD

On October 6, 2017 the State of Illinois implemented its law granting psychologists who obtain specialized training the right to prescribe certain medications to adult patients. Although Illinois is one of only 5 states in which psychologists have prescriptive authority, the Illinois law will likely have the greatest impact on the country. Illinois contains the nation’s third largest city, has 9 medical schools, and a number of World Class Universities. It will be assumed that the law was vetted in a state with medical and psychological sophistication and it would not have passed the Illinois Legislature and been signed by the governor if it was believed to be dangerous to patients.

The Illinois law provides a template for PhD or PsyD psychology programs to construct a curriculum for graduate students to obtain essential training to meet state educational licensing requirements in the use of medications. This can be accomplished by extending required graduate level training for clinical psychologists by approximately 1 year. Current licensed PhD and PsyD clinical psychologists may also obtain prescriptive authority.  The law is so constructed that these psychologists could obtain essential training part time while maintaining their psychology practices over a number of years.

A review of physician-related scope of practice disputes between ophthalmologists and optometrists, primary care physicians and advanced practice nurses, and anesthesiologists and nurse anesthetists, shows that over 1 to 2 decades after winning approval in key states, the non-physician groups won the right to expanded practice throughout much of the country. If this history serves as a guide, psychologists are likely to obtain prescriptive authority in significant portions of the country within the next 10 years.

Physician groups have argued that the groups asking to expand their scope of practice would not be safe practitioners. They have also made the case that should patients be injured under their care, that restrictions be reasserted on their practices. To date, the latter has not occurred for optometrists, advanced practice nurses, or nurse anesthetists.

In looking ahead, it is not not clear how many doctoral level psychology students will extend their training to obtain this additional practice option or how many clinical psychologists will. The American Psychological Association reports that 3500 doctoral level clinical psychologists graduate each year. In 10 years, we do not know how many students will graduate from states with psychologist prescriptive authority curricular programs. If we assume that half this number do and half of these students obtain prescriptive authority, we would add 750 mental health practitioners who can prescribe to the nearly  1500 new psychiatrists who graduate each year. This will lead to new calculations on the essential make up of the mental health work force. 

Although the Illinois law is likely to become the national template for further psychologist prescriptive authority laws, it has some serious flaws. The most significant is that although psychologists in training must be supervised by either physicians, advanced practice nurses, or psychologists with prescriptive authority and in practice must have a collaborative care agreement with a physician, the physician does not need to be a psychiatrist. A psychologist could complete training and then go into practice without ever having his or her clinical work supervised by a psychiatrist. Imagine a psychiatric resident with a faculty of only primary care physicians? Yet a prescriptive authority training program under the Illinois law is not required to have psychiatrist on its faculty and could use only primary care physicians. 

In coming years when prescriptive authority laws are introduced in new states, psychiatry must balance its response in state legislatures between either defeating these laws or compromising by making them better and safer for patients. This will not  be an easy political choice.

In 10 years the practice landscape will change. Clinical psychologists and psychiatrists will need to reassess who and what they are about and how they should relate to each other. In Illinois today it would be possible to staff an inpatient psychiatric unit with psychologists with prescriptive authority and primary care physicians without any psychiatrists. Although psychologists are not authorized to prescribe for children or for adults over 65, the primary care physician can. This possibility is but one potential example of what the future could look like.

Articles

If history serves as a guide, psychologists are likely to obtain prescriptive authority in significant portions of the country within the next 10 years.

Clinical Psychologists and Psychiatrists: Colleagues or Competitors? 

[[{"type":"media","view_mode":"media_crop","fid":"33100","attributes":{"alt":"ABIM Finally Gets It Right","class":"media-image media-image-right","id":"media_crop_6442810522900","media_crop_h":"313","media_crop_image_style":"-1","media_crop_instance":"3485","media_crop_rotate":"0","media_crop_scale_h":"175","media_crop_scale_w":"118","media_crop_w":"211","media_crop_x":"2","media_crop_y":"37","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The American Board of Internal Medicine (ABIM) is not sure if the Maintenance of Certification (MOC) program accomplishes its goal of ensuring maintenance of competency. Richard Baron, MD, President of the ABIM, said in an open letter to the internal medicine community: “Effective immediately, ABIM is suspending the Practice Assessment, Patient Voice and Patient Safety requirements [of MOC] for at least two years.”

 These areas are similar but not identical to elements of two of the American Board of Psychiatry and Neurology’s (ABPN) MOC modules. These programs for both the ABIM and the ABPN are “mandated by the American Board of Medical Specialties.” The ABIM took this action in response to concerns expressed by the internal medicine community about the time expenditures, cost, and questionable value of some MOC protocols.

 reported on February 4, 2015, that “the AMA said in a statement that it was ‘delighted’ that the board was listening to physician concerns and that the ABIM would align the MOC program with principles the House of Delegates called for at its November 2014 interim meeting in Dallas.” The ABIM is the largest board of the American Board of Medical Specialties (ABMS). The ABMS sets the policies that all medical boards follow in establishing certification procedure. Because of its size, the ABIM’s action serves to reopen the debate on whether the ABMS’s currently mandated MOC procedures indeed work and are relevant to ensure the competency of American physicians.

How has the competency of American physicians been determined and ensured?

 report, it was felt that a graduate from an accredited medical school was trained enough to effectively and safely practice medicine. This was eventually altered in most states to require a 1-year hospital-based internship and still later a specialty residency. Each specialty determined the length of its residency. In the 1970s, the internship was merged into initial specialty residency programs. Today, in any number of fields, this period of training is extended further to require specialized training in a subspecialty fellowship.

With the rapid growth of medical knowledge and changing modes of medical practice, it became clear that medical education did not stop when formal training ended. To facilitate lifelong learning for physicians, continuing medical education (CME) programs were developed to ensure physician competence.

Licensure requirements and board certification

Parallel to changes in training were shifts in the timelines for assessing physician competence. All states developed mechanisms to license physicians after graduation from medical school.

Today, state licensing examinations are prepared by the National Board of Medical Examiners in conjunction with the Federation of State Medical Boards. For a state license, a physician must pass 3 examinations.

State licensing boards alone were not seen by some as a totally adequate means of assessing the abilities of medical specialists. To best inform the public of the special competencies of physicians and to ensure that after residency they had the basic competency in their field, various specialty boards were formed. The first was the American Board of Ophthalmology in 1916. Eventually, specialty boards were developed for all areas of medicine. These boards are joined by a common governance and standard-setting body-the ABMS.

Initially, the boards of the ABMS granted lifelong certificates based on varied forms of written and oral examinations. In the 1990s, this shifted under ABMS direction, and all boards granted 10-year certificates after the successful comple-tion of an examination, with a requirement that every 10 years a diplomate of a board would need to take and pass a recertification examination. Approximately 10 years later, the ABMS further changed the system of recertification, now calling it MOC. Board-certified physicians would now be required, in addition to an examination every 10 years, to participate in a number of activities each year. These included proof of ongoing learning activities relevant to their practices and varied self-assessment programs.

The inclusion of yearly requirements raised the question as to whether these programs added to or aided in maintaining competence of practicing psychiatrists. In 2010, I asked this question in an article in 

 I argued that while the required MOC programs of the ABPN added to the workload of psychiatrists, evidence to prove a positive effect on psychiatrist performance did not exist. Larry Faulkner of the ABPN and Kevin Weiss of the ABMS responded in a later article and argued simply that it did.

In 2011, the American Psychiatric Association’s (APA) Assembly passed an action paper requesting that the APA review the MOC process and assess the evidence for its effectiveness. The requested review did not take place. Subsequently, the ABPN altered some of its requirements and psychiatry’s focus on MOC declined.

That is where questions of the value of elements of current MOC programs stood until February 3, 2015. The ABIM did what the AMA did not or could not do. It directly challenged elements of the current MOC required protocols. By suspending some of the MOC requirements and not dropping them, the ABIM has avoided a direct confrontation with the ABMS. A suspension means they still stand but are not enforced. In the next 2 years, the ABIM and ABMS will have to resolve their differences and evidence will need to be presented to support the varied ABMS mandated requirements

Under the cover of the action of the ABIM, the ABPN and the APA need to reassess the ABPN’s MOC program. Where there is no clear evidence of the effectiveness of elements of the program, these requirements should, in my view, be suspended pending further review. Indeed, the ABPN and APA could ask the ABIM to participate in this essential review.

As physicians, we have a responsibility to ourselves and society to ensure our own competency and that of every medical practitioner. All practitioners must participate in activities that ensure their ongoing ability to practice their specialty.

The ABPN has a parallel set of responsibilities to its diplomates and to society. It must ensure that its procedures effectively assess the knowledge and competency of the psychiatrist it certifies. In addition, it must develop programs to effectively assess the lifelong learning and practice abilities of its diplomates. A transparent program to assess the effectiveness of these critical programs is what we need-an MOC program that facilitates these processes is essential. But, it may not be what we have.

Dr Weissman is Professor of Clinical Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine, Chicago.

 ABIM announces immediate changes to MOC program. http://www.abim.org/news/abim- announces-immediate-changes-to-moc-program.aspx. Accessed February 24, 2015.

 Robeznieks A. Docs cheer as ABIM suspends parts of controversial recertification process. February 4, 2015. http://www.modernhealthcare.com/ article/20150204/news/302049939. Accessed February 24, 2015.

Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching

 Weissman S. Does Maintenance of Certification ensure maintenance of competency. 

 Weiss KB, Faulkner LR, Weissman S. Board certification: two perspectives. 

The ABIM is not sure whether the MOC program accomplishes a critical goal of ensuring maintenance of physician competency and has suspended the Practice Assessment, Patient Voice and Patient Safety requirements of MOC for at least 2 years.

ABIM Finally Gets It Right

The first half of the 20th century saw 2 world wars, indiscriminate aerial bombing of civilians, the dropping of the atomic bomb, and the Holocaust-all of which created intense trauma for soldiers and civilians. Yet it was not until the American intervention in a post-colonial civil war in southeast Asia that the psychiatric community in the 1970s formally described what we now call PTSD. Grinker and Spiegel, American psychiatrists, published 

War Neurosis in North Africa: The Tunisian

 which addressed the impact of stress on members of the American Army Air Corps. In some ways their accounts serve as a forerunner of later work on PTSD.

Here, I review factors that led to the codification during the Vietnam War of the symptoms and behaviors that today constitute the diagnosis of  PTSD. I also examine the factors that delayed the process of identifying this disorder to well after the major global upheavals of the first half of the 20th century.

A major element that affected the development of the diagnosis of PTSD was the response of the American public to the Vietnam War in the 1960s and 70s. Although the US had a military draft, the soldiers sent to Vietnam were overwhelmingly from lower socioeconomic groups and minorities. Minorities and the poor bore much of the burden of the war in Vietnam These and other realities gave rise to major antiwar demonstrations by civilians and broad antimilitary campaigns. Concurrently, high incidences of substance abuse were observed in American soldiers in Vietnam and in other US military bases. The substance abuse and other mental health disturbances continued after the soldiers returned home.

The US government wanted and needed an explanation as to why the psychiatric morbidity of Vietnam War veterans exceeded that seen in veterans of World War II and the Korean War. In response, the psychiatric community created the diagnosis of PTSD to account for the behaviors and symptoms observed in veterans who experienced extreme trauma.

It proved difficult, however, to establish clarity and uniqueness for the diagnosis of PTSD. Coexisting substance abuse and symptoms of depression and anxiety blurred the boundaries between these disorders and PTSD. For Vietnam war veterans and all US military veterans, these distinctions are critical. A diagnosis of PTSD entitles veterans to lifelong pensions, whereas a diagnosis of substance disorders does not.


Adding to the difficulty of assessing an individual for the presence of PTSD are the complex factors that determine who is at risk for the disorder and why traumatic events that trigger symptoms and behaviors in one soldier do not in another. The interaction of an individual’s genetics, psychology  and life experiences partially determines his or her responses to severe stress and affects the likelihood that PTSD will develop.

The social context in which an individual lives and works also affects his psychological organization and may either support or impair mechanisms in dealing with stress. The soldier in a unit with members with whom he has trained may experience their camaraderie as supportive. Shared psychological experiences may be internalized in a manner that enhances his ability to deal with combat stress without long-term adverse psychological sequelae. The soldier who has not had shared experiences of trust before combat may feel isolated and more vulnerable during combat, which may make him more vulnerable to PTSD.

Broader societal factors may also contribute either positively or negatively to the development of combat-related PTSD. The morale of the country and its support for a military action may provide a positive background for soldiers, which may be integrated into a psychological system that serves to protect them from PTSD. During the Vietnam war, many American soldiers did not feel supported by the country at large. The lack of accretion of all these elements by American soldiers in Vietnam may have contributed to their being more psychologically vulnerable to develop PTSD than were soldiers of previous wars.


Because of the frequent co-occurrence of PTSD with other mental health problems, it is not surprising that the Institute of Medicine of the National Academy of Sciences

 could not categorically support a specific treatment for PTSD. This does not mean that a given treatment will be ineffective but rather that evidence for proof of efficacy is not available.

Another difficulty in developing therapies for PTSD is that similar symptoms and behaviors may have quite different causal factors, while different symptom patterns may have common causal factors. A required outcome in treating PTSD is that an individual’s psychological mechanisms for maintaining homeostasis are restored. In the absence of a clear understanding of the causal factors responsible for the patient’s symptoms and behavior, it may be difficult to develop effective treatment.

With many psychiatric disorders, we do not know-- other than through information supplied by the patient --  what overwhelmed the patient’s psychological system. As we address the patient’s self-reported experiences, we develop inferences regarding the reported stressors and their effects and develop therapeutic interventions based on our understanding.

With PTSD, the nature of the stress may be explicit; however, knowledge of the patient’s inner life is not. It may be just as important in developing a treatment strategy for a patient with PTSD as it is for other disorders to learn about the patient’s coping strategies and defenes. This knowledge must include an essential understanding of how the patient dealt with stress before the diagnosis of PTSD. Information on comorbid psychiatric disorders and/or medical illness must also be gathered to complete a comprehensive diagnostic assessment and make treatment decisions.

Why it took so long to identify the diagnosis


So: why was PTSD first explicitly described during the Vietnam war? In World War II, pain, suffering, and trauma were seen as natural outcomes of the war. Complaints were viewed as signs of weakness and fear. Focusing on fear as a response to the trauma of war would run the risk of contagion among soldiers or civilians that might leave them unable to endure further stress.

In the Battle of Britain, it was critical for Britain to sustain both military and civilian morale. This required that British leaders communicate a resolve to both the British people and German leaders that Britain would eventually prevail. In that context, there was no room for PTSD. Throughout Europe, bombing of civilian populations brought the same suffering and trauma-everyone experienced the trauma of war.

Understanding the trauma experienced by the victims of the Holocaust-trauma beyond that of the war itself-would have seemed a likely arena in which to define the syndrome. The stories of many Holocaust survivors clearly demonstrate that they suffered from PTSD. But the intensity of the horror and the failure of governments to respond to protect millions of fellow Europeans may have obscured the full impact of the trauma on survivors. In the end, neither psychiatry nor society effectively examined the long-term effects of trauma on the survivors of the Holocaust or survivors of World War II.

During the Vietnam War, the general lack of support and the perception that the outcome of the war did not have any relevance to the security of the US allowed a closer look at the soldiers’ experience of war. With the focus on individual soldiers and their experiences, rather than on the mission or the morale of the country, the ordeal that soldiers faced became the impetus for identifying PTSD and developing treatment programs.


Once a veteran’s dysfunction is understood as a unique response to the horrors of war, it can be addressed and special programs can be implemented to help him or her return to full functioning in society. Special courts to address the needs of veterans as reported in 

The Institute of Medicine of the United States National Academy of Science has commissioned a further review of PTSD, with a goal of clarifying the benefits of a number of therapies. Because of the complexity of how stressors may lead to PTSD, many treatment strategies are needed to provide the best outcomes for patients.

War Neurosis in North Africa: The Tunisian Campaign. 

(January-May 1943). New York: Josiah Macy, Jr, Foundation; 1943.


Board on Population Health and Public Health Practice. 

Treatment of Post Traumatic Stress Disorder: An Assessment of the Evidence.

 Washington, DC: National Academies Press; 2008. 

http://www.nap.edu/openbook.php?record_id=11955&page=1

Goode E. Coming together to fight for a troubled veteran. 

http://www.nytimes.com/2011/07/18/us/18vets.html?pagewanted=all

The first half of the 20th century saw 2 world wars, indiscriminate aerial bombing of civilians, the dropping of the atomic bomb, and the Holocaust-all of which created intense trauma for soldiers and civilians.Yet it was not until the American intervention in a post-colonial civil war in Southeast Asia that the psychiatric community in the 1970s formally described what we now call PTSD.

The Science and Politics of PTSD

Who speaks for doctors these days? The answer was simple 100  years ago. The AMA spoke for the nation’s physicians and concurrently spoke to  the nation’s desire for quality healthcare. In 1908 the AMA’s Council of  Medical Education proposed guidelines for what became the Flexner Report in  1910. The Flexner report served as the model for American and Canadian medical  education for a century. It also placed the AMA in the forefront of healthcare  and made the AMA the premier speaker for our nation’s physicians.

The AMA’s position in health care has been radically  altered. While the AMA refers to itself as the “House of Medicine,” its power  and scope have been reduced from that of a “mansion” to a “bungalow.” Here, I  review those forces and choices in the past century that have lead to a  redistribution of power between medical professional associations and  societies, numerous healthcare enterprises (including insurance companies and  hospitals), and various branches of federal and state government and  practitioners. I also propose responses to the new and rapidly changing medical  landscape to ensure that physician practitioners have appropriate input.

In the years following publication of the Flexner Report,  the AMA proposed and assisted in implementing a number of actions that have had  a major impact on the focus, organization, and practice of medicine. These  included support for the establishment of these agencies (among others):
   •The Federation of State Licensing Boards (FSLB)
   •The American Board of Medical Specialties (ABMS)
   •The Liaison Committee for Medical Education (LCME)
   •The Liaison Committee for Graduate Medical Education  (LCGME), which subsequently became the Accreditation Council for Graduate  Medical Education (ACGME).

In Washington, the AMA was seen as a powerful advocate for  its physician members and powerful determiner of healthcare policy.

Diverse forces have led to the decline in AMA authority to  speak for the profession. They include the growth of specialization, which has  led to an erosion of its members. In political discussions about healthcare, a  war chest for lobbying and members equals power. The AMA has seen reductions in  both. With the growth of specialization, individual physicians began to choose  between belonging to medical specialty societies or the AMA and its affiliate  state medical societies.

AMA membership peaked in 1960; at that time, 74.5% of  physicians were members.

 Today, fewer than 20% of physicians are  AMA members. In contrast 60% of psychiatrists in the US are members of the  American Psychiatric Society.

Although the AMA has no direct role in the governance of  medical specialty societies, it maintains a connection to these societies  through its House of Delegates. These societies may send voting delegates to  the AMA House of Delegates. In recent years medical specialty society  membership has also declined. These societies now face competition from  subspecialty societies. Additionally young physicians are less likely to belong  to professional organizations than their more senior colleagues.

The AMA once played a central role in developing and  implementing policy in many of the organizations it created. Today its role in  these and other medical organizations is either reduced or inconsequential.  More importantly, its Boards and Councils have become essentially self-perpetuating  and have limited or no direct input from organizations that represent  practitioners. This absence of diverse broad-based input from practitioners may  adversely effect the decision making of these Boards. For example the ABMS  developed Maintenance of Certification (MOC) polices both to assess and  promulgate activities to maintain physician competence. Some assert that these  policies do neither and thus not only do not aid physicians but also may also  fail to serve the needs of society.2

Concurrent with these changes in medicine’s self-governance  is the expansion of government involvement at the local, state, and federal  levels in healthcare as manifested in Medicare and Medicaid, the National  Institutes of Health, the FDA, as well as other federal government agencies.  The federal government is now the major source of funding and policy  determination for American healthcare. The recent passage of the Accountable  Care Act has further involved the federal government in the direction of health  care. These changes have occurred as the AMA’s power at the national level has  declined.

In dealing with the federal government the AMA has obtained  mixed results. In a number of areas, such as the development and maintenance of  CPT codes, the AMA has retained a significant interest. After having opposed  federal initiatives from social security to Medicare, the AMA supported key  aspects of healthcare reform. This effectively gave the AMA a place at the  healthcare policy table along with a number of other healthcare players.

But its place is now significantly reduced as it deals with  growing federal involvement in all areas of healthcare practice as other major  players in healthcare such as the American Hospital Association, the insurance  lobby and others exercise their political power. Yet on the federal level and  in issues that engage federal agencies and federal legislation, it is likely  even with its reduced influence, decision makers believe the AMA still speaks  for today’s doctors.

Because of its reduced influence and with growing incursions  on medical practice, physicians must ask what organizations now speak for us.  Specialty medical associations do, though on broad legislative and regulatory  issues they have had limited power. On special issues related to their  specialty, however, they can assert authority and bring about change. The  American Psychiatric Association (APA) did this in fighting for and in  obtaining mental health parity legislation.

The most critical role for medical specialty associations  may be to represent their members in areas where our society allows the  profession to establish its own rules. These include areas of medical education  and in Board Certification. Medical specialty societies must address the  American Board of Medical Specialties to ensure that the ABMS standards of  initial certification and Maintenance of Certification meaningfully address  physician competence.

Specialty societies must also ensure that the procedures for  maintenance of certification relate to the actual practice of medicine. In  residency education, these societies must ensure that training program  standards prepare residents for actual practice of medicine in their specialty.  This will require a more active involvement by these societies in establishing  professional educational training standards. These initiatives by specialty  societies relate to physician professional self-governance.

To make these boards and councils that relate to the  practice of medicine more effective, I propose that the members of the Boards  or councils must spend between 25% to 50% of their time in clinical practice.  If you do not practice, how can you know what the issues are in contemporary  medical practice?

These needed reforms will allow practitioners to assert an  active role in professional self-governance. The reforms would aid in ensuring  the competence of practitioners and our service to society. But these essential  actions may be of limited impact on physicians and healthcare as our nation  struggles to develop major fiscal reform. Reform of funding our nation’s  healthcare and social support systems is likely to occur in the coming years.

The US cannot continue to rely on China to buy our bonds to  fund critical federal programs. We also cannot afford to spend nearly twice as  much to fund our healthcare system as do other industrialized countries without  evidence of discernable better healthcare outcomes.

In Washington every medical or healthcare group as well as  every interest group has hired the best lobbyists they can afford to urge the  government to accept their vision of the future. For practitioners to have a  say in what will be the political equivalent of a street brawl, all physician  groups must first coalesce and then develop a mutually agreed on plan for  reforming healthcare in US. This plan must be presented to society at large and  to the administration and congress. To paraphrase Benjamin Franklin. . . if  physicians do not hang together at this stage of negotiations, we shall  assuredly all hang separately as others take change of healthcare reform.

This is a critical time for American Medicine. The reforms  that will occur will shape healthcare and medical practice for decades. We must  ask our leaders to lead and represent us.

American Medical Association Archives. Physician  Membership, Chicago: American Medical Association. 2009.


Weissman S. Does maintenance of certification ensure  maintenance of competency? Psychiatric Times. 2011. 

http://www.psychiatrictimes.com/display/article/10168/1773715

Who speaks for doctors these days? The answer was simple 100 years ago. The AMA spoke for the nation’s physicians and concurrently spoke to the nation’s desire for quality healthcare. . . .Today, fewer than 20% of physicians are AMA members.

Who Speaks For Today’s Physicians?

In reviewing the practice patterns of psychiatrists today, it is clear that many provide mostly medication checks or medication management for their patients. The conventional wisdom for this model of practice is that it is based on current methods of payment for clinical service, which places a premium on brief interventions by psychiatrists. Medications must be prescribed by a physician, while a non-MD mental health worker can provide psychotherapy and be paid by an insurance company at a lower unit cost than that paid to a psychiatrist to perform the same form of treatment.

Although it is true that today’s economics encourage the practice of medication management by psychiatrists, the current structure of clinical experiences in residency training programs may also serve to implicitly encourage and support this model of practice.

The practice of psychiatry is the merger of scientific disciplines that inform us in understanding behavior and caring for our patients. The science of psychiatry is taught effectively in most, if not all, psychiatric residencies by a graded curriculum that addresses the biology, psychology, and social factors of human behavior. Resident performance on the psychiatric resident training examinations (PRITE) taken during each year of residency and the written examination of the American Board of Psychiatry and Neurology for certification confirm that current graduates are well versed in the varied aspects of the science of psychiatry.

The art of psychiatric practice is learned by residents during various supervised clinical rotations. Each rotation has a number of stated learning objectives and related competencies that a resident must master. But once the resident masters the required competencies, is he or she in fact able to perform these required competencies? The ability to perform in a clinical rotation may not mean that the resident has the competence to practice unsupervised. In assessing performance during or after a rotation, we must determine whether the resident will be able to practice in the field.

While one learns science in an academic framework, the art of psychiatry is learned experientially, in graded supervised settings. The skill set grows with increased experience. In psychiatry more than any other medical specialty, the art of being a psychiatrist is most critical. The psychiatrist’s core knowledge, skills of interviewing, and his or her empathic capacity serve as the diagnostic imaging and laboratory tests of other medical specialties.

The only activity that the psychiatric resident is able to master . . . is . . . prescribing medication . . .

The psychiatrist performs a diagnostic assessment by talking to the patient and to individuals in the patient’s life. After completing the diagnostic interview, the psychiatrist may obtain information from other professionals and from laboratory results. A unique form of information for psychiatrists regarding their patients, which is frequently not acknowledged in both the diagnostic and therapeutic process, is the psychiatrist’s empathic sense of the patient. Using all the collected data, the psychiatrist makes a DSM diagnosis and answers any special concerns regarding the patient. At this point, a treatment plan is developed. Assessing patients and developing and instituting a treatment plan is the essence of the psychiatric residency.

Once the psychiatric resident completes the primary care and neurology rotations, he will start to work on psychiatry inpatient units. Typically, the resident works with an attending psychiatrist and sees 7 or 8 patients daily. Attending psychiatrists must see the patient and play a key role in the patient’s treatment or they cannot bill for their services. This is a change from 20 to 40 years ago, when the resident was the only doctor to see the patient.

Today, the resident and the attending psychiatrist make a joint diagnosis and work with other members of the team, such as a nurse and a social worker, to develop a treatment plan. Frequently, the only role for the resident is for the medication treatment of the patient. The resident may participate in family interventions, but work with the patient’s family is usually left to the social worker. Because of the rapid turnover of inpatients (5 to 7 days on average), psychotherapy is usually not an important part of the treatment. Stabilization with medications and group therapy are the core of the treatment. In the course of his rotation, the resident may see more than 300 patients. Once a patient is discharged, the resident is often unable to follow up with him and does not know the outcome of the treatment unless a patient is readmitted.

At the end of the rotation, the resident can perform diagnostic assessments, work with others to develop a treatment plan, and direct the medication management of a patient. The resident may not, however, be knowledgeable about the extended impact of the medication on the patient.

The resident may then move on to a psychosomatic medicine rotation for 2 months, consulting on patients in medical or surgical units. The resident’s primary responsibility is to make a quick diagnosis and propose a rapid intervention in conjunction with the medical or surgical team and nursing staff. During the supervised consultations, the resident participates in a psychiatric subspecialty, where he may be more of an observer than an active participant. Once again, because of today’s short duration of hospital stays, the resident has limited knowledge of the outcome of his treatment interventions.

On child psychiatry rotations, the resident’s active role in working with children may be limited. The resident functions primarily as an observer. Clinical work is usually heavily supervised and observed. A similar experience may occur on a 2-month rotation in geriatric psychiatry.

In most residencies, outpatient work is a minimum of 12 months in the resident’s third year. The resident is given diverse supervised responsibilities and is required to develop abilities in a number of psychotherapies, including dynamic psychotherapy. Residents generally have between 3 and 5 dynamic psychotherapy cases at a time. If we assume each patient is in treatment an average of 4 months, the resident could have between 12 and 15 patients in psychotherapy during the course of the year. Many of these patients would also be taking medication, and a significant number of other patients would be seen only for medications.

Residents can quickly demonstrate in formats constructed by their teachers that they can perform a number of tasks. However, on their own-outside of their residencies-their skills may be limited. One masters an art by the repetition and learning about oneself and one’s abilities. Unfortunately, in many residency programs, the only activity that the psychiatric resident is able to master in this fashion is in prescribing medication. Experience with a handful of patients in dynamic psychotherapy may not be adequate for the resident to feel that he has mastered psychotherapeutic skills. It is not surprising that on graduation, many residents pursue a career in which their main role is medication management.

Many of today’s residencies reinforce mastering only the art of applying knowledge of the biology of behavior, which informs the use of medications. The unanswered question is, can modern clinical psychiatry survive if training programs provide clinical experiences that may produce expertise in only one of psychiatry’s core disciplines?

Residents must be given adequate time during their training to learn and incorporate the psychological and social elements critical to being a psychiatrist. If psychiatry reduces or abandons its engagement with psychology and social science in understanding and treating mental disorders and focuses predominantly on the biological factors of mental disorders, what will our role as psychiatrists be? Other physicians may assume the responsibility for medicating patients with mental disorders, and others may take on the role of integrating the biological, psychological, and social forces that have an impact on behavior.

 If psychiatry reduces or abandons its engagement with psychology and social science in understanding and treating mental disorders and focuses predominantly on the biological factors of mental disorders, what will our role as psychiatrists be? 

Are We Training Psychiatrists to Provide Only Medication Management?

Dr Sidney Weissman made some interesting observations in his 

 regarding the American Board of Psychiatry and Neurology’s (ABPN) Maintenance of Certification (MOC) program.

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.



Larry R. Faulkner, MD, President and CEO


American Board of Psychiatry and Neurology

Weissman S. Does maintenance of certification ensure maintenance of competency? 

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.

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

Two perspectives regarding the American Board of Psychiatry and Neurology’s (ABPN) Maintenance of Certification (MOC) program. 