One Small Step For Physician Autonomy

Physicians have been oppressed in the United States for the past 30 years - nearly the entire length of my career. That is not rhetoric. It is a fact. The oppression has occurred at the level of federal and state governments and eventually the businesses that those governments actually support.  A lot of it is documented on this blog and I am not going to repeat it here.  The most recent twist on that oppression has been in the form of maintenance of certification (MOC) actively promoted by the American Board of Medical Specialties (ABMS).  All medical specialty organizations in the United States are members of the ABMS and are forced to abide by its rules.  Some specialty organizations  started their own MOC that did not involve ABMS procedures and they were told they had to all go through the same process.  That process involves testing and intrusive measures into a physicians practice.  It is a major departure away from life-long learning that physicians aspire to and use to shape their individual practices.

The move to MOC was initiated by ABMS on their own and well before there was any debate of the evidence.  As an example, I was board certified by the American Board of Psychiatry and Neurology (ABPN) in 1988.  There was no time limitation on the original certifications until 1990.  I was certified Added Qualification in Geriatric Psychiatry in 1991; but that certification was time limited 1991-2001.  I was re-certified in Geriatric Psychiatry ten years later and that certificate states Recertified 2000-2010.  I was also certified Added Qualifications in Addiction Psychiatry 1993-2003.

Somewhere around the time I was due for certification for Addiction psychiatry, I asked myself: "Why are you doing this?" It costs a thousand dollars to take the test.  The test did not confer any special status, privileges, or salary.  It did not change any study habits at all.  I was still attending quality CME courses, reading the literature, and incorporating it into my practice. I was teaching and that is always associated with needing to know a lot more about current debates in the field as well as the representative scientific literature.  Even though I have never failed one of these board exams, there is a ritual of needing to take time off and study material that may not be immediately relevant to your practice - medical and psychiatric trivia that is an essential part of standardized test gamesmanship.  So I decided no - I am a professional. I am at the top of my game and all indications are that things are going well.  Even if they weren't, a thousand dollar board exam or even MOC procedure is not remedial.  It does not provide any feedback. It is essentially a prep school exercise of jumping thorough another hoop.  You either make it or you don't.  At that time there had been 7 hoops* and that was enough.  I stopped the process at that point. 

My guess is that a lot of other physicians saw the light the same way that I did.  My further speculation is that the ABMS reacted by increasing their leverage first by not issuing lifelong original certifications like they gave me back in 1988 and then making those re-certifications as onerous as possible.  I am not being dramatic when I use the term onerous.  I thought about getting back into the current MOC stream about a decade ago at an APA convention and talked with the ABPN representative at their booth. At the time, he literally could not tell me what I had to do to resume the endless cycle of paying fees and taking tests only that there was even more to do than that.  Not an inspiration to get back into the process.

Since then the ABMS has become much more strident about the MOC process.  They were playing the odds.  Physicians and their professional organizations are generally politically clueless and ineffective.  The best evidence of that is their inability to prevent managed care advocates in both government and business from taking over the field and dramatically decreasing the quality care.  They made arguments about how it was necessary to maintain quality and knowledge in a field.  How does that happen by taking a trivial pursuit style exam with no feedback and a very high pass rate?  How does that happen by basically doing patient satisfaction surveys on my patients - a procedure that is rapidly falling into disrepute in clinical settings. 

In the interest of brevity, I am not going to point out all  of the logical errors or overt conflict-of-interest in the ABMS arguments.  There are many bloggers out there who have done outstanding job of that including Cardiologist Westby G. Fisher, MD, FACC and Psychiatrist Jim Amos, MD.  In the literature the standard bearer against the MOC process has been Cardiologist Paul Tierstein, MD who was instrumental in founding the alternate board certification process through the National Board of Physicians and Surgeons (NBPAS). 

My conclusion after wading through all of the politics for that past decade was to get re-certified though NBPAS for several reasons including:

1.  Meaningfulness -  the existential equivalent of that word meaninglessness has been with me since I read Yalom's classic book Existential Psychotherapy in 1982. Yalom referred to it as the fourth ultimate existential concern - right after death, freedom and isolation.  Becoming a practicing physician is an exercise in delayed gratification.  As an intern and a resident the term "busy work" is used to designate tasks that have to be done but don't seem to advance true knowledge or understanding. It is really not clear what your professional life is going to be like until you are in the field interacting with colleagues and patients and practicing medicine.  Physicians as a group are overachievers, overwork, and compulsively question themselves about their decisions.  They are not work averse at all.  One of the motivators to expend this kind of energy is doing meaningful work.  Dr. Tierstein emphasizes this on the last slide in his lecture.  MOC is busy work and its meaning is arbitrarily defined by outsiders. 

2.  It reflects the original ABMS process - we certify you to go out in the world, practice medicine, and keep up with the theoretical and clinical aspects on your own as a professional.  Working with very bright colleagues providing excellent care for 30 years validates that approach.

3.  It certifies my ongoing work - I hope it is apparent from this blog that I am not a casual reader of the psychiatric literature.  I study it at several levels. I have two rooms in my home that are covered from ceiling to floor with medical and psychiatric literature.  I correspond with interested colleagues around the world.  I attend conferences.  I am working on current research.  I teach. I consider all of this life-long scholarship.  At one point the ABPN suggested they were going to put an asterisk (*) next to the names of lifetime certificate holders unless they participated in MOC.  To me that is an insult to my current work and professionalism. It's like designating me as some kind of steroid user.

4.  The NBPAS certifies continuing medical education credits (CME) - my state medical board asks me to report the total number every three years.  There is a suggestion that they will audit all of my certificates, but in 30 years that has never happened.  NBPAS does not certify you until you meet their CME requirement and send them all of the certificates via their web site.  They have an excellent website that can accept uploads of at least 10 of these documents at a time.  So here is a powerful reason for every state medical board to use NBPAS certification.  It immediately means that CME requirements are met very 2 years and they are certified.     

5.  It reflects what I do in my clinical work - sub-specialization in any field is always controversial.  Does there need to be another division in the field?  Is there enough evidence that it is far enough away from what everyone else is doing to be a separate body of knowledge?  After 30 years of work - I say no.  I still see geriatric patients, patients with general psychiatric disorders, patients with addictions, and patients with medical problems every day.  It's not like I can go to a magical clinic somewhere and just see a patient who only has one problem affecting their brain.  To do a good job, you have to continue to know it all.  It is hard work and there are often not a lot of clear answers, but that's why it is called practice and that's why we love medicine.

6.  It is tremendously cost effective considering what gets certified - the financial incentives for the MOC movement are huge and funded by physicians.  Stepping out of the MOC loop makes a clear statement.

7.  It is view consistent with my political philosophy -   I am from blue collar roots and was socialized to suspect the motives of politicians, businessmen, and even union organizers.  Very little of my experience as an adult seems to counter that perspective.  I see health care being run by the same mechanisms as the financial services industry and not for the benefit of physicians or their patients.  NBPAS certification is an antidote to the ABMS Big Brother approach.  In Dr. Tierstein's video he points out why it is no accident that healthcare companies insist that any physician working for them have MOC.  It is all part of the conflict-of-interest driven ruling class approach to business and regulation that we should expect.

That is why I got the NBPAS certificate.  I understand that there are early career physicians locked into some HMO who are told they need to be in the MOC cycle or they will lose their privileges and job (further evidence BTW of what MOC really is).  I can't understand younger physicians who don't recognize splitting when they see it.  I have read their opinions about how some think they know more than older physicians and how they are more tech savvy and how they are not averse to managed care manipulations.  I will just say that being an expert takes more than writing a smart phone app or thinking that you know every thing in the field after passing the initial board exams.  The true innovators and experts that I know have been doing what they innovated for the past 20-30 years.

The bottom line for this post is irrespective of where you are in medicine, if you ignore the politics you do so at your own peril.

Currently MOC is at the top of that list. 


George Dawson, MD, DFAPA




References:

1: Teirstein P, Topol EJ. Maintenance of Certification Programs and the Interstate Medical Licensure Compact--Reply. JAMA. 2015 Sep 1;314(9):952. doi: 10.1001/jama.2015.8912. PubMed PMID: 26325571.

2: Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA. 2015 May 12;313(18):1809-10. doi: 10.1001/jama.2015.3576. PubMed PMID: 25965219; PubMed Central PMCID: PMC4751049. 

3: Teirstein PS. Boarded to death--why maintenance of certification is bad for doctors and patients. N Engl J Med. 2015 Jan 8;372(2):106-8. doi: 10.1056/NEJMp1407422. PubMed PMID: 25564895.

Supplementary:

*  The 7 hoops included part 1, 2, an 3 of the National Board Exams to qualify for a medical license and the subsequent 4 certifications and recertifications by the ABPN.  After thinking about this there were actually 8 hoops because there were actually 2 ABPN ceritifying examinations for psychiatry.  Part One was a written exam on psychiatry and neurology including imaging questions.  Part Two was an Oral Board exam that consisted of two parts.  One half of the day was an examination based on an observation of a videotaped interview. The other half of the day was an examination based on your observed interview of the patient.  Part Two had a higher failure rate probably due to a high degree of subjectivity.  I knew people who failed it more than once. So that is really a total of 8 tests altogether.


         

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"


I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
 
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.


George Dawson, MD, DFAPA



Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)

The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.

2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.

Member Referendum	Support	5,525 (80%)
	Do not support	1,418 (20%)

The referendum did not pass. APA received ballots from 25% of the voting members.

The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:


The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.

GD