Board Approves Response to ABPN on General, Subspecialty MOC Process

At its October meeting, held in conjunction with IPS: The Mental Health Services Conference in New York, APA’s Board of Trustees dealt with an action-oriented agenda. Perhaps the issue with the most immediate impact on members was the discussion on maintenance of certification (MOC).

Ellen Dallagher

Prior to the meeting, the Board had been asked by the American Board of Psychiatry and Neurology (ABPN) for input on the question of whether maintenance of general psychiatry certification be a prerequisite for maintaining certification in a psychiatric subspecialty. The Board unanimously decided that there should not be more than one MOC process.

Current ABPN policy is that psychiatrists (with the exception of child psychiatrists) must maintain certification in general psychiatry and in their subspecialty. In response to the query, Trustees voted to convey the following five points in a letter to ABPN President Larry Faulkner, M.D.:

• APA does not agree that there should be an exam every 10 years for MOC.

• Certification of lifelong learning should be an integrated, ongoing process relevant to actual practice.

• APA is willing to work with the ABPN to improve the MOC process.

• For subspecialists taking a recertification exam, the ABPN should ensure that the exam primarily consists of questions related to the diplomates’ subspecialty. Any general psychiatry questions that are included should be relevant to the diplomates’ practice.

• No psychiatrist should be forced to maintain her/his underlying general and subspecialty certification through more than one certification process.

Ellen Dallagher

APA President Renée Binder, M.D., said at the meeting that feedback on the question of separate MOC subspecialty requirements was garnered from the councils on Medical Education and Lifelong Learning, Geriatrics, Psychosomatic Medicine, Children and Adolescents, Psychiatry and Law, Addictions, and the Assembly Work Group on MOC. While there was some disagreement on the question of separate certification processes, there was general agreement that the ABPN should simplify requirements and continue to offer combined exams and that the examinations should reflect the knowledge set required for actual practice.

The Assembly MOC work group provided the following statement: “The strongest reason to [oppose the current ABPN policy of requiring separate MOC processes for generalist and subspecialty practice] is that like child psychiatrists, some other specialists do not practice much if any general psychiatry, and it would be irrelevant to their practice to have to study for the general exam. There was further consensus that the requirement to do both will be a barrier to recertification as it is onerous, time consuming, and of no value to have to do both. We believe that, above all, recertification should cover relevant topics to the clinical practice of the individual, and therefore the individual should be able to decide in what areas to recertify.”

Binder noted that the American Board of Internal Medicine had previously voted that internists who subspecialize (such as cardiologists) do not have to maintain certification in general internal medicine.

“We believe in the principle of lifelong learning, but it should be relevant to practice,” Binder said. “If there is an exam, it should include questions about what the physician is actually doing in practice. We are volunteering to work with the ABPN and other representatives to develop reasonable standards for MOC.”

Criteria for Responding to Social Issues

In other business, the Board approved four criteria by which APA could be guided when challenged to respond to social issues that may or may not have immediate bearing on psychiatric practice or psychiatric patients. The criteria, recommended by the Ad Hoc Work Group on Social Issues, chaired by Assembly Speaker Glenn Martin, M.D., are as follows:

• APA should have substantial expertise or perspective to offer.

• Positions should be relevant to access to care or the prevention, diagnosis, or treatment of psychiatric disorders.

• The issue being considered should be significant for psychiatrists and their patients.

• APA should develop positions on issues on which APA may have a meaningful impact and positively shape public opinion.

“Our charge was to come up with some criteria for if and when APA should take a stand on what some people might call social issues,” Martin said at the meeting. “There are a lot of different perspectives among our members, and many say we should just focus on issues directly relevant to psychiatry. There are others who say we should take a more activist stand on social issues.”

Martin cited gun control, abortion, and the death penalty as the kind of issues on which there are differing opinions. He said the ad hoc work group was composed of members on both sides—those who favored a more activist stance on social issues and those who favor a more conservative approach focusing on issues directly relevant to psychiatry.

The other six members of the work group are Lama Bazzi, M.D., Scott Benson, M.D., Brian Crowley, M.D., Elizabeth Henderson, M.D., Gail Robinson, M.D., and Altha Stewart, M.D.

Assisted Outpatient Treatment Discussed

The Board also heard a report from Steven Hoge, M.D., chair of the Council on Psychiatry and the Law, and Marvin Swartz, M.D., corresponding member of the council, on a proposed position statement on assisted outpatient treatment (AOT). The proposed position statement, which includes 15 recommendations, will be voted on by the Board in December.

In an interview with Psychiatric News after the meeting, Swartz said pending mental health reform legislation in Congress includes provisions regarding AOT so the council believes it is important for APA to formulate policy on the issue.

“Basically, the position we take is that outpatient commitment can be effective if it is systematically implemented, if it includes the intensive services necessary to meet the needs of the patient, and if it is sustained for a reasonable period of time,” Swartz said. “If a state is going to implement AOT, it has to be purposeful, and it has to include the combination of services necessary to make it meaningful. And it takes time.”

Swartz added, “It is a controversial procedure because there are people who think that the court has no business ordering people into treatment if they haven’t broken the law,” Swartz said. “And often it is the mental health system that has failed a person.

“That’s a strong point, but we believe that AOT can also provide guidance to the system,” he said. “AOT is also a court order for the mental health system to prioritize care. When someone is under a court order, they get priority—they get attention and services.”

Swartz added that the council evaluated the AOT program in New York state and found that it did reduce hospitalization and arrests and saved the state approximately 50 percent in the first two years (Psychiatric News, November 6). “When we asked patients about their experience with the program, generally those with serious mental illness responded that if they really get the benefits of AOT—a place to live and consistent treatment—then they are willing to trade off their freedom to get those benefits.” ■