Maintenance of Certification in Psychiatry
Michael H. Ebert, MD (Chair)
Yale University School of Medicine, New Haven, Connecticut
Larry Faulkner, MD
American Board of Psychiatry and Neurology, Inc, Buffalo Grove, Illinois
Dorothy E. Stubbe, MD
Yale University School of Medicine, New Haven, Connecticut
Daniel K. Winstead, MD
Tulane University School of Medicine, New Orleans, Louisiana
Maintenance of board certification (MOC) is currently being deployed by the ABMS and its member boards, including the ABPN. Michael H. Ebert, MD, chaired a discussion of MOC and the core competencies for physicians with Larry Faulkner, MD; Dorothy E. Stubbe, MD; and Daniel K. Winstead, MD.
History of the Core Competencies
Dr Ebert explained that, in 1999, the ACGME and the ABMS identified 6 general principles to aid in the organization and assessment of medical education as a way to address the growing concern for quality improvement in health care; these principles relate to patient care, medical knowledge, interpersonal skills and communication, practice-based learning, professionalism, and systems-based practice (See Table 1, AV 1).1 Soon after these core competencies for all specialties were developed, added Dr Faulkner, the ABPN (a member board of the ABMS) sought to identify how the core competencies applied to psychiatry and neurology, and subsequently published its consensus findings in the book Core Competencies for Psychiatric Practice: What Clinicians Need to Know: A Report of the American Board of Psychiatry and Neurology, Inc.2
History of Maintenance of Certification
Besides the core competencies, the ABMS also developed an MOC program for board-certified physicians with the following 4 components: professional standing, self-assessment and lifelong learning, cognitive expertise, and performance in practice. Dr Faulkner stated that the ABPN designed its own MOC program to address the 4 broad components of the ABMS MOC program as well as each of the 6 core competencies (See Table 2, AV 2).3 Dr Ebert pointed out that many diplomates, particularly those with lifetime certificates, do not feel that they can take considerable time off to recertify themselves. Dr Faulkner stated that the ABPN has tried to balance meeting the rigorous ABMS requirements while establishing a program that is reasonable and feasible for its members (AV 3).
Dr Ebert explained that the MOC process is a concerted effort to bring about fundamental change in lifelong learning in the profession of medicine, which starts in residency. Dr Winstead and Dr Faulkner agreed that the MOC movement strives to put credibility and relevance back into the system and to remind clinicians that lifelong learning is a cycle of identifying areas of weakness in one’s practice, seeking education in those areas, and then improving practice.
The Involvement of the ABMS in the ABPN MOC
Dr Faulkner explained that the position of the ABPN and a number of other member boards of the ABMS is that it is the responsibility of the ABMS to promulgate broad standards or guidelines for the 4 components of MOC, and it is the responsibility of the member boards to develop the unique programs that will meet those broad guidelines. However, the ABPN is concerned about the aggressive timetable imposed by the ABMS for implementation of newer components of MOC (See Table 3). Few options are currently available for psychiatrists to meet performance-in-practice requirements.
The ABPN is working with the APA and other organizations to encourage the development of products that diplomates can use to fulfill performance-in-practice requirements. The ABPN has historically taken the position that, other than the certification exam, it does not develop products for its diplomates to buy to fulfill ABPN requirements, explained Dr Faulkner. The ABPN instead has depended upon affiliated professional organizations to develop self-assessment, CME, and performance-in-practice modules.
Reasons to Participate in MOC Programs
Because MOC is a voluntary process for diplomates who received board certification before 1995, Dr Stubbe inquired about the compelling reasons why diplomates with lifetime certificates should participate. Dr Faulkner recognized that the majority of ABPN diplomates do hold lifetime certificates, but increasing numbers of people with lifetime certificates are stepping forward to participate in MOC, whether it be for academic interests, stature, professional satisfaction, or outside pressure (AV 4).
The FSMB recently passed a resolution suggesting that programs similar to MOC should be required for physicians to maintain their licenses to practice medicine. If states decide to adopt those policies, then lifetime certificates may rapidly disappear. If these policies are adopted, MOC should be accepted as adequate evidence to maintain licensure, in Dr Faulkner’s opinion.
Incorporating Core Competencies and MOC Components Into Medical Training
Dr Stubbe explained that a new focus in residency training is to help graduates prepare for both the self-assessments and the peer evaluations of MOC (AV 5). Medical students, who have been in school many years, may be accustomed to receiving feedback from instructors but not to assessing their own areas of weakness. Practice performance assessment by peers requires that the practitioner be able to use medical records and organize charts in such a way as to demonstrate his or her logic.
Dr Stubbe observed that faculty or administration members of academic centers may not regularly see patients and asked how those physicians would complete MOC practice requirements. Dr Faulkner explained that the ABMS wants its member boards to use categories of board certification specifying whether the diplomate is clinically active or clinically inactive. To maintain certification, an administrator or a researcher would complete the other components of MOC but be designated as clinically inactive (AV 6).
Enforcing and Refining MOC Components
Dr Ebert inquired about oversight of MOC components. Dr Faulkner explained that the FSMB provides frequent feedback to the ABMS, which is then provided to the ABPN, about whether any licensure issues for candidates need to be addressed, such as restrictions that may cause a member to no longer be certified. The ABPN is in the process of developing modular MOC examinations so that individuals who are board certified in multiple specialties might be able take exams in all of their subspecialties (up to 4) in 1 sitting. Additionally, Dr Faulkner is working with the APA, AACAP, and other groups to encourage them to review and adapt existing practice guidelines to allow diplomates to quickly identify whether their practices are consistent with those guidelines. Sample performance-in-practice tools based on recommendations in the APA guidelines for major depression have been created.4
Benefits of MOC in Psychiatry
Dr Ebert stated that MOC could benefit psychiatrists by addressing patient safety, uniformity of practice, and quality of psychiatry in the United States (AV 7). Dr Stubbe added that MOC programs would also help psychiatrists develop more positive habits with regard to keeping up with the literature, ensuring that they are providing the best treatments, and following best practices in general. She hopes that MOC will also engender an atmosphere of increasing openness about performance in practice. Dr Winstead commented that, for a long time, he has worried that psychiatrists may use legitimate concerns about patient confidentiality as a way to cloak their practices against peer assessment. Dr Faulkner concluded that MOC provides an external, unbiased mechanism to help physicians assess their own competence.
For Clinical Use
- MOC programs are required by the ABMS and are implemented by specialty boards to ensure high-quality physician education and patient care
- The MOC program for psychiatry and neurology focuses on a 10-year cycle of learning that asks board-certified physicians, or diplomates, to perform regular self-assessments and receive peer assessments to pinpoint areas to improve before recertification
- Graduate and residency programs are working to integrate the 6 core competencies and 4 MOC components into their training in order to establish a foundation for lifelong learning
- The MOC requirements continue to be refined, and diplomates should seek detailed updates
AACAP = American Academy of Child and Adolescent Psychiatry, ABMS = American Board of Medical Specialties, ABPN = American Board of Psychiatry and Neurology, ACGME = Accreditation Council for Graduate Medical Education, APA = American Psychiatric Association, CME = continuing medical education, FSMB = Federation of State Medical Boards, MOC = maintenance of certification, PIP = performance in practice
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- American Board of Medical Specialties. MOC Competencies and Criteria. Available at: http://www.abms.org/Maintenance_of_Certification/MOC_competencies.aspx. Accessed Feb 11, 2009.
- American Board of Psychiatry and Neurology. Scheiber SC, Kramer TA, Adamowski SE, et al, eds. Core Competencies for Psychiatric Practice: What Clinicians Need to Know: A Report of the American Board of Psychiatry and Neurology, Inc. 1st ed. Washington, DC: American Psychiatric Publishing, Inc.; 2003.
- American Board of Psychiatry and Neurology, Inc. Maintenance of Certification for Psychiatry. Available at: http://www.abpn.com/moc_psychiatry.htm. Accessed Feb 11, 2009.
- Fochtmann LJ, Duffy FF, West JC, et al. Performance in practice: sample tools for the care of patients with major depressive disorder. Focus. 2008;6(1):22–35.