Janis Bacon Petzel, MD, DFAPA
Psychiatry and Geriatric Psychiatry, MaineGeneral Medical Center, Augusta, Maine
Dr. Petzel has disclosed that she has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
Editor’s note: This is an op-ed piece. It reflects the opinions of the author and does not necessarily reflect the opinion of Carlat Publishing.
The American Board of Psychiatry and Neurology’s (ABPN) new Maintenance of Certification (MOC) process has created an uproar in many physician circles. It’s not the idea of proving competence that inflames strong emotions among physicians, it’s the manner in which MOC is being implemented (Inglehorn JK and Baron RB, N Engl J Med 2012;367(26):2543–2549; Drazen JM and Weinstein DF, N Engl J Med 2010;362(10):946–947).
Those who object to MOC cite a number of arguments, the strongest of which are outlined here:
MOC does not prove competence: I could find no research data showing that board certification has any relationship to quality of care, patient safety, or cost of medical care. The high pass rate of the MOC exam (99%) indicates that psychiatrists are hardly incompetent—although it might also suggest the exam is too easy; either way, exam scores themselves don’t differentiate good psychiatrists from mediocre ones (http://bit.ly/YPYCUS).
Time burden and redundancy: Most psychiatrists are employees of medical systems. We are already doing yearly in-house “quality improvement” exams for ethics, patient safety and others; as well as peer review activities; and are reporting CME to state licensing boards. MOC is one more set of redundant and questionably effective tasks that pile on to over-paperworked doctors. Some of the MOC requirements (eg, patient evaluations) present certain complications or conflicts of interest if you do forensics or treat patients with dementia, addictions, or personality disorder, although this requirement was recently modified to require feedback from patients OR peers.
Expense: The $1,500 MOC exam is technically only good for one year. True, you take the exam every 10 years, but as soon as you pass, you enter the MOC cycle. You will have to pay annual fees and do a complex set of tasks in order to keep your board certification in working order. The yearly fees pre-pay for the next exam ten years in the future, whether you decide to take the exam or not.
Only certain “products” (ABPN’s term), many of which have to be purchased, are acceptable to meet the Self-Assessment (SA) and Performance in Practice (PIP) requirements.
Remember, your subspecialty boards expire when your general boards do. If you screw up and miss a deadline, your board certification will be publicly noted on the ABPN verifyCERT page (bit.ly/XBXBPt) to be out of compliance.
PotentialABPN financial conflict of interest: Based on IRS 990 forms, the ABPN, despite its not-for-profit status, has racked up millions of dollars in net revenue since the MOC process started (http://bit.ly/YQ255G). The GuideStar web site allows you to view IRS Form 990 financial reports for ABPN. The ABPN’s reported expenses stayed roughly constant over those years, so one might wonder what’s happening with all that money.
Threat to physician workforce: MOC requirements may be the last straw for many psychiatrists to leave the profession. A survey by the Maine Association of Psychiatric Physicians, a district branch of the APA, found that over one-third of respondents stated that they were considering retirement rather than do MOC. Reduced numbers of psychiatrists will make access to mental health care more difficult for patients.
Mission creep: A potentially much greater expense if you decide to opt out of MOC may be your inability to work. Board certification was never intended to be a requirement for employment, but times have changed. Board certification is now a de facto, if not actual, requirement for employment and insurance panel participation.
The bottom line for individual psychiatrists is that MOC is an unpleasant fact of life. Deciding to opt out is likely to cause you grave problems with employment and with insurance reimbursement, while complying with MOC imposes a tremendous burden of time and money, and may say absolutely nothing about your competence as a psychiatrist.
Few of us have the strength or wherewithal to swim against that current on our own. But the ABPN may respond to resistance. It has already modified some of its requirements in response to physician outcry. The APA finally got involved and managed to negotiate some modest changes.
Physician pushback may carry some risk. Gordon Smith, executive vice president of the Maine Medical Association warns, “The public may perceive that psychiatrists do not want to stay current in their field. This perception can be enhanced by the Boards themselves. The ABPN can be expected to aggressively defend what they are doing, so may put out information echoing what the public might be thinking.”
We also need to watch our backs close to home. There is a new trend among state medical boards to link Maintenance of Licensure (MOL) with MOC, a potential nightmare. Individual doctors cannot fight MOL alone, either. We need strength in numbers.