Assembly Backs Blocking MOC as a Condition of Licensure

Maintenance of Certification, physician wellness and burnout, and solitary confinement of juvenile detainees were among the issues considered by APA’s Assembly at its meeting held in conjunction with APA’s 2017 Annual Meeting in San Diego.

Assembly members voted in favor of APA adopting the position that decisions regarding licensure, hospital privileges and credentialing, and/or participation on insurance panels should not in any way be conditioned upon a physician’s completion of or participation in Maintenance of Certification (MOC) or Osteopathic Continuous Certification. This position will be brought before the Board of Trustees at the Board’s meeting in Washington, D.C., this month.

MOC, especially the Part IV Performance in Practice component, has been the source of enormous consternation among physicians across medical disciplines who have found the Part IV requirements cumbersome and not clinically meaningful. In an address two years ago to the APA Assembly, American Board of Medical Specialties (ABMS) President and Chief Executive Lois Margaret Nora, M.D., J.D., acknowledged that the MOC process, and in particular the Part IV performance-in-practice component, needs to be improved and refined. She said that the ABMS was responding to physician concerns by a “relaxation” of requirements and an expansion of activities that count toward fulfillment of Part IV.

But she also said she believed that Part IV should be retained and in time would be “embraced” by physicians. “I have heard from physicians who say, ‘Part 4 has changed my practice for the better. We are doing things now that have improved the quality of care our patients receive.’”

(“Performance in practice” refers to a requirement that physicians build into their routine practice the capacity to assess their performance continually against guidelines for best practices and make improvements to meet those guidelines.)

At press time, six states—Georgia, Kentucky, Maryland, Missouri, Oklahoma, and Tennessee—had enacted legislation stating that physician licensure cannot be contingent on completion of MOC requirements. Two other states—Michigan and Texas—have similar legislation pending.

“The Assembly and the membership have voiced their grave concerns on the issue of MOC,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., told Psychiatric News after the meeting. “Members see the closed-book MOC exam as being behind the times, and they express concern that the exam content is not relevant to their individual practice. Similarly, members have expressed concern that there is a large opportunity cost associated with these exams, which require them to take time away from their practice and families to study and travel to exam centers.”

Physician Wellness a Priority

In other business, the Assembly approved an action paper to continue the mission of the Ad Hoc Work Group on Physician Well-Being and urged APA to develop resources for increasing awareness about physician burnout, depression, and suicide, as well as interventions for promoting physician wellness, including recommendations for institutional response to physician suicide.

The action paper also calls on APA to do the following:

• Revise its 2011 Position Statement on Physician Wellness to affirm APA’s commitment to ensuring the well-being of its members and to encourage members to serve as leaders in promoting well-being initiatives within their institutions, training programs, and systems of care.

• Promote further investigation of the underlying causes of increased rates of burnout, depression, and suicide among physicians and to expand the evidence base for innovative wellness interventions.

• Work with stakeholder organizations, including the Federation of State Medical Boards, to remove questions about treatment for psychiatric disorders, including substance use, from licensing applications (initial or renewal) and employment applications and instead focus on relevant, current functional impairment due to either physical or mental illness.

• Collaborate with the AMA to develop joint initiatives to prioritize these issues.

• Work with the Accreditation Council for Graduate Medical Education to encourage residency programs to improve access to mental health treatment for residents and fellows, recognizing that such facilitation will likely take different forms and may vary based on a variety of program and institutional factors.

Other Actions

Assembly members also voted for APA to support the AMA policy statement opposing the use of solitary confinement in juveniles and to draft its own position statement on this issue by May 2018.

The Assembly also voted for APA to adopt and promote the international Neuroscience-based Nomenclature (NbN) standard terminology in its publications, policies, and communications and seek opportunities to promote adoption of NbN terminology by payers and policymakers. The NbN is a project of five international psychopharmacological research organizations to rename psychopharmacological medications to more accurately reflect their neurobiological action in the brain.

The five international organizations spearheading the project are the European College of Neuropsychopharmacology, the American College of Neuropsychopharmacology, the Collegium Internationale de Neuropsychopharmacologie, the International Union of Basic and Clinical Pharmacology, and the Asian College of Neuropsychopharmacology.

In a paper published in July 2014 in European Neuropsychopharmacology, members of a task force representing the five groups (including David Kupfer, M.D., chair of the DSM-5 Task Force) proposed a new template comprising a multi-domain pharmacologically driven nomenclature. The domains are class of drug, referring to primary pharmacological target and relevant mechanism; family, reflecting the relevant neurotransmitter and mechanism; neurobiological activities; efficacy and major side effects; and approved indications.

In an interview with Psychiatric News last year, Kupfer said the five domains represent varying levels of complexity—depending on the needs of patients, clinicians, pharmacologic researchers, and basic scientists—but the essential feature of the template is that it would replace indication-based titles with a nomenclature based on pharmacology and neurobiological action. An example of this would be the reclassification of the drug clomipramine—casually referred to as an “antidepressant.” According to the NbN proposal, it would be reclassified as a “serotonin reuptake inhibitor.” Also under the proposal, perphenazine, referred to as an “antipsychotic,” would be called a D2 receptor antagonist. ■