Reimagining ABPN Board Certification: A Fusion of Tradition and Technology

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Where does the journey of becoming a board-certified psychiatrist lead us in the era of technological advancements and artificial intelligence (AI)? This question lies at the heart of the ongoing evolution in psychiatric education and evaluation. In this commentary, I aim to reignite a crucial discussion about the future of the American Board of Psychiatry and Neurology (ABPN) board examination process—a discussion that is as much about preserving the core values of psychiatric practice as it is about embracing innovation.

Around 2006, the ABPN ushered in a transformative change in their candidate assessment procedures. The traditional approach—comprised of widespread live patient examinations and examiner-conducted interviews—was replaced with a novel strategy: clinical skills evaluations (CSE) spread across the duration of the candidate's residency, coupled with a final multiple-choice examination overseen by the ABPN. Factors like cost, grading inconsistencies, and low pass rates drove this change, representing a crucial moment in psychiatric evaluation history.^1-5

In this commentary, I aim to invigorate discussion about the ABPN board examination process, considering the rapid advancements in video technology and AI. This discussion aligns with the ABPN’s mission.⁶ Psychiatry residents undergo a demanding journey to achieve board certification, mastering CSEs conducted by board-certified psychiatrists and excelling in a challenging multiple-choice final exam. However, I argue that an essential element has been lost during these transformative changes.

Unlike other medical specialties, psychiatry uniquely required a live patient interview as an essential component of board certification. This requirement was pivotal because it allowed candidates to demonstrate key psychiatric competencies: developing rapport and showing empathy, conducting an efficient 30-minute diagnostic interview, analyzing and coherently presenting interview findings, articulating and justifying DSM diagnoses, and formulating a comprehensive treatment plan with prognosis.

The existing multiple-choice exam, while efficient, does not fully capture the essence of what “board certification” should signify for emerging psychiatrists. In an era where we balance tradition and innovation, I propose a revitalized “comprehensive” part II oral board exam. This exam would incorporate contemporary tools such as video communication and AI, ensuring a thorough and modern evaluation of the skills vital to psychiatric practice.

Central to this revamped system is the reestablishment of live evaluations, in which candidates demonstrate their expertise during a live 30-minute assessment of a new patient. This interview could transpire either at specified locations or remotely, utilizing the capabilities of videoconferencing. As video sessions have become the commonplace in psychiatry in the post-COVID-19 era, they offer an efficient and effective platform for communication as well as for testing.

One scenario might be for the candidate to conduct a live interview of a new patient, but have the ABPN examiners observe the interview remotely via videoconferencing. This method would negate the need for examiners to disrupt their schedules or incur travel costs. Examiners could thus conduct their 30-minute examinations from their own offices, resulting in substantial time and cost efficiencies.

Contrasting the current CSE examinations, these examiners, akin to previous times, would not be associated with the candidates’ programs, which guarantees a degree of objectivity not achieved in the current CSE process.

Furthermore, actual patient interviews more accurately assess a psychiatrist’s clinical skills, as they evaluate the ability to gather information, form diagnoses, and develop treatment plans. Answers to multiple-choice questions, on the other hand, can be memorized, but exams do not truly test these skills.

Actual patient interviews provide a more realistic assessment, mirroring the real-world scenarios in which psychiatrists must think critically and make decisions quickly. In addition, actual patient interviews help psychiatrists develop their communication skills, which are essential for effective interactions with patients, colleagues, and other health care professionals.

An alternate scenario would involve candidates conducting their patient interviews via videoconferencing. As in the previous scenario, ABPN examiners could remotely observe the interview, then conduct their examination of the candidate, as mentioned above.

Critics may argue that the problem of bias, perhaps on the part of the possible “bias” of the ABPN examiners toward certain candidates, or the luck of the draw of being assigned “difficult” vs “easy” patients for the exam remains. However, following Voltaire’s argument that “the perfect is the enemy of the good,” it does not follow that sacrificing the tradition of live patient exams on the altar of absence of bias will lead to better qualified psychiatrists achieving the privilege of “board certification.”

In order to maximize the efficiency of offering live patient interviews and examinations, candidates who prefer this to a video interview experience can perhaps be coordinated with the annual meeting of the American Psychiatric Association (APA), which regularly attracts thousands of psychiatrists. Many of the “board examiners” and candidates may already be attending these meetings, resulting in significant time and expense savings for all involved.

To address concerns about inconsistency in scoring interviews and examinations, I propose exploring the development of new AI-driven scoring systems. By designing an AI engine or plugin that evaluates candidates based on audio or video recordings, we could potentially achieve more accurate and consistent results. Initially, this system could run in parallel with traditional examiner scoring, allowing for comparison and assessment of whether AI can reliably replace human scorers.

Reimagining the ABPN board examination process in psychiatry by reintegrating actual patient interviews and leveraging technology and AI can offer a dynamic, efficient, and fair certification system. This approach combines the best of tradition and innovation, ensuring that psychiatrists are evaluated on their clinical skills, decision-making abilities, and communication competencies. The potential benefits of this approach seem to outweigh the challenges.

To move forward with this reimagined certification process, it is essential for the ABPN Board of Directors to carefully evaluate the feasibility and implementation of these changes. Pilot studies and collaboration with experts in the field can help refine the process, address concerns, and ensure the highest standards of professionalism and patient care.

In conclusion, the reimagining of the ABPN board examination process in psychiatry holds great promise. By reintegrating actual patient interviews and leveraging technology and AI, we can create a dynamic and fair certification system that aligns with the realities of modern psychiatric practice.

It is an opportunity to combine tradition and innovation, ensuring that psychiatrists are well-prepared to meet the complex challenges of providing high-quality mental health care. The path forward involves careful consideration, collaboration, and a commitment to continuous improvement, ultimately benefiting both psychiatrists and the patients they serve.

Dr Hyler is professor emeritus of psychiatry at Columbia University Medical Center.

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References

1. Rues VI. The examination in psychiatry. In: Aminoff MJ, Falkner LR. Eds. The American Board of Psychiatry and Neurology: Looking Back and Moving Ahead. American Psychiatric Publishing; 2012.

2. Moran M. ABPN exam changes to focus on clinical skills. Psychiatric News. 2007. Accessed June 25, 2023.

3. Moran M. Computer tests will replace oral part of board exam. Psychiatric News. September 5, 2008. Accessed June 25, 2023. https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.43.17.0001

4. Moran M. ABPN announces timetable for phasing out oral exam. Psychiatric News. February 6, 2009. Accessed June 25, 2023. https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.44.3.0004a

5. Moran M. New ABPN executive sees big changes for board exam. Psychiatric News. May 19, 2006. Accessed June 25, 2023. https://psychnews.psychiatryonline.org/doi/10.1176/pn.41.10.0010

6. Mission. American Board of Psychiatry and Neurology, Inc. Accessed June 25, 2023. https://www.abpn.com/about/mission-and-history/