By now you’ve probably heard about the American Board of Psychiatry and Neurology’s (ABPN) new Maintenance of Certification (MOC) Program for psychiatrists. If you haven’t taken some action dictated by the new process, we have some bad news—you're probably already behind. The good news is that there’s still plenty of time to catch up. In this article, we’ll lay out the key points and let you know what you have to do now in order to keep up with your certification renewal.

Why The Change in Process?
Back in the day, all we had to do to maintain our certification was to take a multiple-choice exam every 10 years. But, according to the ABPN, this was not enough to make sure doctors were keeping up with medical knowledge and practice guidelines. A growing focus on theneed for doctors to maintain and prove clinical competence led them to revise their MOC program.

By the way, while this article focuses on renewal of certification, you should know that the notorious oral exam for initial certification is also being eliminated. This test, which involved interviewing a patient in front of a panel of judges, was causing too much PTSD in candidates, and many questioned whether it was a truly valid test of competency anyway. The new system will rely on residencies to demonstrate interviewing skills.

Research lends some support to ABPN’s creation of more stringent educational criteria: A 2005 report in the Annals of Internal Medicine showed that there is an inverse relationship between the number of years a physician has been in practice and factual knowledge, appropriate standards of care, and patient outcomes. In this review of 62 studies, 32 of them (52 percent) showed a correlation between decreased performance and number of years in practice for all outcomes measured. (Outcomes included knowledge, adherence to standards of practice, appro-priate treatment, and actual health outcomes, such as mortality.) Only four of the 62 studies focused on psychiatrists, three of which linked poorer competence with increased years in practice (Choudhry NK et al., Ann Intern Med 2005;142(4):260–273).

What’s New?
The new MOC program has four components and is designed to “phase in” over a multi-year period, so that every piece of the program will be in effect by 2017. Psychiatrists who were lucky enough to have received their initial board certification before 1994 have a “lifetime” certification and are not required to complete any of the MOC steps, although they are welcome to. And don’t worry, if you have a lifetime certificate and decide to take the MOC exam anyway, you will not lose your lifetime certificate even if you fail it.

The rest of us—those originally board certified after 1994—will have to live with these new requirements. As you read about the many new steps, don’t get too anxious. Other than the results of the final computerized MOC exam, you don’t actually have to furnish any documentation that you’ve completed all the steps. It’s all on the honor system.

However, the ABPN will audit a small fraction of candidates to prove that they have done the required work.
Although chances are slim that you’ll be one of the unlucky ones who gets chosen for review, you should keep clear records of all of your activities, just in case.

There are now four requirements for renewing your certification: 1. Maintaining professional standing; 2. Self assessment and lifelong learning; 3. Performance in practice; and 4. Cognitive expertise. Here are the nitty gritty details of each.

1. Professional Standing. Nothing new here. You must have an unrestricted license to practice medicine in at least one U.S. state or territory or Canadian province to be considered for recertification.

What you need to do now: Get yourself a medical license!

2. Self-Assessment and Lifelong Learning. By requiring “self-assessment,” the ABPN is not forcing you to go into therapy. The self-assessment and lifelong learning portion of your recertification means participating in enough—and the right kind—of continuing medical education (CME) activities. Since 2007, these new standards have required that you complete an average of 30 CME credits each year. Many of you probably already earn close to this quota anyway, because most medical boards require nearly this many to maintain your basic medical license.

These yearly requirements will add up to 300 CME credits for each 10-year span of recertification. They will need to be split so that you earn 150 in the first five years and 150 in the second. Note that this CME must be the official “AMA PRA Category 1 Credits” to qualify. (For Canadian physicians, they must be accredited by the Royal College of Physicians and Surgeons of Canada.)

Where do you find these credits? Wherever you normally get your CME—such as CME newsletters, conferences, grand rounds, and, increasingly, web-based CME courses.

Eight of your yearly CME credits need to be from activities that qualify as “self-assessment” activities. Self-assessment CME is just like regular CME except that it provides you with more feedback about your performance. For example, after you take the post-test, you’ll get suggestions for literature to read in order to learn more, and you’ll find out how your performance compares to your peers. Based on this more detailed feedback, ABPN expects you to plan future CME activities to remedy any gaps in your knowledge.

How do you know whether a particular CME course qualifies as self-assessment CME? You can check the ABPN website, which lists a few approved courses. For example, there is the APA’s FOCUS, a somewhat dry journal-based CME, that for $296 for APA members (and $476 for nonmembers) provides up to 40 credits per year, 20 of which qualify as “self-assessment” (http://bit.ly/aKI612); or the American College of Psychiatrists’ Psychiatrist in Practice Examination, a more engaging web-based exam that presents clinical vignettes and accompanying multiple choice quizzes, costs $249, and provides up to 30 “self assessment” CME credits (http://acpsych.org/pipe).

According to Pattie Vondrak, the director of MOC at ABPN, the board plans to add many more CME activities to their list. In the meantime, if you are unsure, simply ask the organization providing the CME if it qualifies as ABPN self-assessment CME.

What you need to do now: This CME requirement is currently in effect, so you should already be working on getting your 30 Category 1 CME credits each year regardless of when you are up for recertification. The phase-in of the self-assessment requirement began in 2010, so if you were last certified in 2001 or later, you need to start getting some self-assessment CME credits under your belt.

3. Performance in Practice (PIP). The PIP component is perhaps the biggest change for psychiatrists. Each PIP unit consists of a “clinical module” and a “feedback module.” Here’s what you’ll have to do:

For each clinical module, you will collect data from five patients of your choosing whom you’ve treated over the previous three years. You’ll compare this data to various “best practices” guidelines, such as those from your hospital’s quality improvement program or published practice guidelines. Based on those comparisons, you’ll figure out which clinical skills you need to work on, and then you will come up with a plan for improvement. Within two years of this, you’ll collect data on five patients again (new patients or the same group) to see if your clinical activity has improved in the areas you identified.

For example, let’s say you noticed in one of your charts that you put a patient on an antipsychotic without getting an initial weight or a serum lipid panel, as is recommended in many practice guidelines. You make a note of this omission, and you try hard to do better. Two years later, you pull another chart (it can be the same patient) documenting that you have become more scrupulous in following patients’ weights and lipid profiles.

For the feedback module, you’ll askfor feedback about your clinical activities from five patients and five peers of your choosing. Based on this feedback, you’ll figure out any areas you need to improve on and create and implement a plan for improvement. Within two years—you guessed it—you’ll solicit feedback from another or the same five patients and five peers to see if your clinical activity has improved.

According to ABPN, your “peers” are “other professional healthcare staff such as psychologists, social workers, physicians, counselors, and nurses.” If you’re in private practice, you can ask for feedback from therapists you share patients with, for example. If you work for a hospital or health system, soliciting feedback from peers will be easier, and in fact, if you have a peer review process in place, it may fulfill the feedback module requirement. You can learn more about that on the ABPN website, where there are a number of sample forms available.

What you need to do now: Anyone who is due for recertification in or after 2014 will have to start complying with this requirement. This really means that you need to start working on your first PIP now, because of the two-year timeframe between your initial chart review and peer or patient feedback and the required follow-up. For those who will be recertified in 2014 or 2015, one PIP unit is required for recertification. For those recertified in 2016, two are required. For anyone recertified in 2017 or any year after, all three units are required for recertification.

4. Cognitive Expertise. Once you’ve completed all of the previous steps, the final step is to take the official MOC Cognitive Exam—the same type of test that we have already been taking under the old recertification system. For an outline of the questions on this test, you can visit the ABPN website.

What you need to do now: Keep good records and make sure you complete all the previous steps. Remember to apply to take the MOC test a year before your current certification runs out—otherwise, you’ll miss the deadline.

Where to Find Help
It seems that the biggest challenge lay ahead for those of you who were certified or recertified in 2009, 2008, and especially 2007. Ms. Vondrak told us that, although you need to meet the requirements by your next recertification year, you won’t be penalized for playing a little bit of catch up if you’ve already missed some deadlines (such as the first PIP unit, which is due between year one and three of your recertification, and which has already passed for those recertified in 2007).

The ABPN website (www.abpn.com) has a lot of information, including links to approved self-assessment tools, details on completing PIP modules, and FAQs. The Board has created a helpful “Physician Folios” tool on its site (you can see it here: http://bit.ly/b7S3J8).

Once you log on to this, you enroll yourself in a program that will send you reminders of what’s due when. So get cracking—it’s time to add yet more items to our ever lengthening to-do list!