Richard Rosin, MD

It’s been almost a year since I published a lengthy critique of the irrationality and arbitrariness of our current maintenance of certification process. I was concerned that there was no clearly articulated, evidence-based justification for these practices.

This is ironic, precisely because the underlying rationale has been an appeal to the importance of practicing evidence-based medicine. The same does not apply to the maintenance of certification (MOC) process, and therefore, what is preached (or mandated?) isn’t practiced. To date, there is still no definitive study proving that MOC and recertification exams improve physician performance.

I made the point that it made no sense that if public safety were really the main goal of recertification, then no one should be “grandfathered” and all diplomates should have to recertify. MOC should be relevant, affordable, and not onerous. I argued that peer review as practiced at Veterans Affairs hospitals and in English-speaking countries was a far more effective way of reviewing our practice and ensuring patient safety.

I also asked why my recent recertification in geriatric psychiatry, passed with flying colors, would be invalidated unless I recertified in general psychiatry. And I wanted to know why the same did not apply to child and adolescent psychiatrists. My exasperation increased to lorazepam-requiring levels, when I entered a bureaucratic labyrinth of fruitless attempts to obtain rational explanations for these anomalies from superiors in the higher echelons of the American Board of Psychiatry and Neurology (ABPN).

Responses, if I got them, were vague and referred to consensus at meetings by nameless committees. I was advised by one correspondent, who claimed to have been at one of the meetings, that there was to be an announcement in one of the newsletters I receive online from the American Association for Geriatric Psychiatry (AAGP). To date, there has been no mention of the issue, and the person who I was told by another person led the discussion could not recall that this topic had ever been discussed. (I have the correspondence to prove this.) He did cheerfully (I think) tell me that he had written both exams and that the process hadn’t been too onerous. I think he might have been trying to tell me that if he could do it without complaining, then so could everyone else.

Then I actually got to meet Dr. Larry R. Faulkner, the ABPN’s CEO, at last year’s ABPN MOC session at the American Psychiatric Association’s annual meeting in Toronto. I felt a touch of nervousness when I introduced myself as “the person who wrote to ask why the requirements were different.” For all I knew, there might have been others, but Dr. Faulkner’s eyebrows rose in a sort of recognition. We shared a joke about how relieved he was that I didn’t appear deranged. I wondered if perhaps he might have been a little disappointed, as at least he’d then have had the option of calling security.

I was able, in my most diplomatic tone – I am after all, a diplomate of the ABPN – to once again pose the vexed question about why it was that child psychiatrists were not required to maintain their certification in general psychiatry as well. This time, Dr. Faulkner did not defer to some anonymous committee at the AAGP, but said the decision was based on the fact that geriatric psychiatrists are more likely to see adult patients than are child psychiatrists. He regarded me with the assurance you’d expect from someone confident that he’d had the last word. I had no idea of the statistics, which I assumed supported his pronouncement. “I see,” I said. Dr. Faulkner smiled again. Game over.

“I’m a child psychiatrist, and I’d say about 40% of my practice is adult psychiatry” said a man next to me who had been listening to our conversation. Dr. Faulkner frowned.

“I’m a geriatric psychiatrist. I’d say about 10% of my practice is adult psychiatry,” I chirped.

Dr. Faulkner frowned again. He looked at his watch.

“Anyway,” he said.

We looked at him. He shrugged.

“Yeah, well what can you do?” he said.

We shrugged.

“Gotta go; nice meeting you,” he said.

“Yeah,” we agreed.

“I guess he gets lots of complaints,” I said to the child psychiatrist.

“Don’t we all,“ he said.

But I digress. Or maybe not. What does this all have to do with MOC? The whole debate on MOC erupted when Dr. Paul Tierstein, a cardiologist in La Jolla, Calif., organized a petition signed by thousands of internists frustrated by increasingly expensive, onerous, and irrelevant requirements by the American Board of Internal Medicine (ABIM). The ABIM leadership ignored its members, shrugging and equivocating and asserting its will. Once the petition was signed and the anger palpable came apologies and backtracking. Then Kurt Eichenwald of Newsweek got hold of the story. He went on to expose financial malfeasance at the ABIM. The diplomates were paying for the executives’ lavish salaries, bonuses, and perks, including a condo, with their hard-earned recertification fees. It didn’t look good.

The ABPN quickly sent out a statement proclaiming its differences from the ABIM, boasting of greater responsiveness. To prove it, the ABPN even made one of the part IV performance in practice (PIP) modules optional – the one where you get your friends and colleagues to fill in forms and give you excellent performance ratings. No doubt, ABPN officials were afraid of a similar revolt among their own members – who were snarling in the online chat rooms. But ABPN officials weren’t ready to give up – especially the lucrative parts of MOC like recertification exams and their “approved products” for the PIP clinical modules. They continued to assert that only their version of MOC was valid while implying that anyone critical of their approach wasn’t serious about maintaining their expertise.

Dr. Tierstein and his associates created a new board, the National Board of Physicians and Surgeons (NBPAS). More and more hospitals are accepting its certification, which costs much less than the ABMS member boards. Many of us have joined. I suspect more are thinking about it. The NBPAS’ main requirements are previous certification by an ABMS member board and 50 hours of CME in the previous 24 months. If your certification has lapsed, you must have 100 hours. You must be licensed and in good standing. The NBPAS is not a free-for-all but a reasonable alternative to the ABMS.

But the ABPN and other member boards are fighting back. MOC exams are alive, well, and exorbitantly priced. The application fee for the exam is $700 for a form that takes less than 5 minutes to fill in. The exam fee is $700. And the late application fee is an additional $500.

The ABPN recently sent out an enthusiastic memo with a whole new set of tasks to complete, apparently pertaining to patient safety. Who could argue about the importance of that? Except it includes topics like “corporate compliance, the deficit reduction act, infection control, and preventing occupational exposure,” which aren’t always hugely relevant in psychiatry. Anyway, the bureaucrats at the hospitals we work for are equally adept at submitting us to hours of mind-numbing “trainings” in these subjects. Who knows why the ABPN got in on the act as well? Could it be the “approved products” on sale to fulfill these new requirements?

That the ABMS member boards’ main focus is pecuniary is further suggested by the enormous compensation its CEOs and presidents receive. They may not be in the same league as Wall Street investment bankers, but they earn on average two to four times more than the doctors whom they have subjugated under the MOC yoke. For those interested, the following link is instructive. We discover that according to the IRS, our own Dr. Faulkner is well remunerated.

We are unlikely to get answers as long as the ABPN and other member boards issue directives and refuse to engage in meaningful dialogue with their diplomates. It really is about how they see their role. Is it collegial and collaborative as they like to imply with their smooth rhetoric? Or is it to regulate and control as suggested by their stonewalling and unwillingness to engage until they receive petitions from large numbers of angry members?

It will be interesting to see what will unfold as alternatives such as the NBPAS gain traction. It costs $169 to become board certified with the NBPAS.

Ironically, we already have peer review processes in university hospitals and health care systems, which really assess our performance in practice. Most doctors know that you can pass any number of multiple-choice exams and still not practice good medicine. Peer review can be done cheaply and truly reflects our clinical practice. Our British and Australian colleagues have opted for a similar approach with peer groups for mid-career psychiatrists. But one suspects that our boards will not approve activities where they cannot collect fees.

That, sadly, is the state of our MOC process. Hopefully, next year, there will be better news.

We need our own Dr. Tierstein for that to happen. Or maybe we should begin by joining the NBPAS, where he already represents our interests.

Postscript:

I had just finished writing the above article when I received a mass communication from the ABPN dated Feb.19, 2016. While maintaining Part IV of MOC, the board has now given us the option of completing either the Feedback Module or the Clinical Audit Module. So there is progress, although one can’t help wondering why ABPN officials changed their minds after previously insisting how critical the PIP modules were. What they don’t plan to do yet is discontinue the recertification examinations. And not surprisingly, the “approved products.” Ironically, Part IV, if implemented as our U.K. and Australian colleagues have done, would be far more reflective of MOC than examinations, though far less lucrative.

The other piece of good news is that on Feb. 22, we received a survey from the AAGP essentially asking what we thought of the discrepancies in recertification requirements between child and geriatric psychiatrists. Clearly I’m not alone, and implicit in the questions is a concern about geriatric psychiatrists not recertifying. (I wonder why.)

Maybe 2016 will prove to be a good year, after all.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.

It’s been almost a year since I published a lengthy critique of the irrationality and arbitrariness of our current maintenance of certification process. I was concerned that there was no clearly articulated, evidence-based justification for these practices.

This is ironic, precisely because the underlying rationale has been an appeal to the importance of practicing evidence-based medicine. The same does not apply to the maintenance of certification (MOC) process, and therefore, what is preached (or mandated?) isn’t practiced. To date, there is still no definitive study proving that MOC and recertification exams improve physician performance.

I made the point that it made no sense that if public safety were really the main goal of recertification, then no one should be “grandfathered” and all diplomates should have to recertify. MOC should be relevant, affordable, and not onerous. I argued that peer review as practiced at Veterans Affairs hospitals and in English-speaking countries was a far more effective way of reviewing our practice and ensuring patient safety.

I also asked why my recent recertification in geriatric psychiatry, passed with flying colors, would be invalidated unless I recertified in general psychiatry. And I wanted to know why the same did not apply to child and adolescent psychiatrists. My exasperation increased to lorazepam-requiring levels, when I entered a bureaucratic labyrinth of fruitless attempts to obtain rational explanations for these anomalies from superiors in the higher echelons of the American Board of Psychiatry and Neurology (ABPN).

Responses, if I got them, were vague and referred to consensus at meetings by nameless committees. I was advised by one correspondent, who claimed to have been at one of the meetings, that there was to be an announcement in one of the newsletters I receive online from the American Association for Geriatric Psychiatry (AAGP). To date, there has been no mention of the issue, and the person who I was told by another person led the discussion could not recall that this topic had ever been discussed. (I have the correspondence to prove this.) He did cheerfully (I think) tell me that he had written both exams and that the process hadn’t been too onerous. I think he might have been trying to tell me that if he could do it without complaining, then so could everyone else.

Then I actually got to meet Dr. Larry R. Faulkner, the ABPN’s CEO, at last year’s ABPN MOC session at the American Psychiatric Association’s annual meeting in Toronto. I felt a touch of nervousness when I introduced myself as “the person who wrote to ask why the requirements were different.” For all I knew, there might have been others, but Dr. Faulkner’s eyebrows rose in a sort of recognition. We shared a joke about how relieved he was that I didn’t appear deranged. I wondered if perhaps he might have been a little disappointed, as at least he’d then have had the option of calling security.

I was able, in my most diplomatic tone – I am after all, a diplomate of the ABPN – to once again pose the vexed question about why it was that child psychiatrists were not required to maintain their certification in general psychiatry as well. This time, Dr. Faulkner did not defer to some anonymous committee at the AAGP, but said the decision was based on the fact that geriatric psychiatrists are more likely to see adult patients than are child psychiatrists. He regarded me with the assurance you’d expect from someone confident that he’d had the last word. I had no idea of the statistics, which I assumed supported his pronouncement. “I see,” I said. Dr. Faulkner smiled again. Game over.

“I’m a child psychiatrist, and I’d say about 40% of my practice is adult psychiatry” said a man next to me who had been listening to our conversation. Dr. Faulkner frowned.

“I’m a geriatric psychiatrist. I’d say about 10% of my practice is adult psychiatry,” I chirped.

Dr. Faulkner frowned again. He looked at his watch.

“Anyway,” he said.

We looked at him. He shrugged.

“Yeah, well what can you do?” he said.

We shrugged.

“Gotta go; nice meeting you,” he said.

“Yeah,” we agreed.

“I guess he gets lots of complaints,” I said to the child psychiatrist.

“Don’t we all,“ he said.

But I digress. Or maybe not. What does this all have to do with MOC? The whole debate on MOC erupted when Dr. Paul Tierstein, a cardiologist in La Jolla, Calif., organized a petition signed by thousands of internists frustrated by increasingly expensive, onerous, and irrelevant requirements by the American Board of Internal Medicine (ABIM). The ABIM leadership ignored its members, shrugging and equivocating and asserting its will. Once the petition was signed and the anger palpable came apologies and backtracking. Then Kurt Eichenwald of Newsweek got hold of the story. He went on to expose financial malfeasance at the ABIM. The diplomates were paying for the executives’ lavish salaries, bonuses, and perks, including a condo, with their hard-earned recertification fees. It didn’t look good.

The ABPN quickly sent out a statement proclaiming its differences from the ABIM, boasting of greater responsiveness. To prove it, the ABPN even made one of the part IV performance in practice (PIP) modules optional – the one where you get your friends and colleagues to fill in forms and give you excellent performance ratings. No doubt, ABPN officials were afraid of a similar revolt among their own members – who were snarling in the online chat rooms. But ABPN officials weren’t ready to give up – especially the lucrative parts of MOC like recertification exams and their “approved products” for the PIP clinical modules. They continued to assert that only their version of MOC was valid while implying that anyone critical of their approach wasn’t serious about maintaining their expertise.

Dr. Tierstein and his associates created a new board, the National Board of Physicians and Surgeons (NBPAS). More and more hospitals are accepting its certification, which costs much less than the ABMS member boards. Many of us have joined. I suspect more are thinking about it. The NBPAS’ main requirements are previous certification by an ABMS member board and 50 hours of CME in the previous 24 months. If your certification has lapsed, you must have 100 hours. You must be licensed and in good standing. The NBPAS is not a free-for-all but a reasonable alternative to the ABMS.

But the ABPN and other member boards are fighting back. MOC exams are alive, well, and exorbitantly priced. The application fee for the exam is $700 for a form that takes less than 5 minutes to fill in. The exam fee is $700. And the late application fee is an additional $500.

The ABPN recently sent out an enthusiastic memo with a whole new set of tasks to complete, apparently pertaining to patient safety. Who could argue about the importance of that? Except it includes topics like “corporate compliance, the deficit reduction act, infection control, and preventing occupational exposure,” which aren’t always hugely relevant in psychiatry. Anyway, the bureaucrats at the hospitals we work for are equally adept at submitting us to hours of mind-numbing “trainings” in these subjects. Who knows why the ABPN got in on the act as well? Could it be the “approved products” on sale to fulfill these new requirements?

That the ABMS member boards’ main focus is pecuniary is further suggested by the enormous compensation its CEOs and presidents receive. They may not be in the same league as Wall Street investment bankers, but they earn on average two to four times more than the doctors whom they have subjugated under the MOC yoke. For those interested, the following link is instructive. We discover that according to the IRS, our own Dr. Faulkner is well remunerated.

We are unlikely to get answers as long as the ABPN and other member boards issue directives and refuse to engage in meaningful dialogue with their diplomates. It really is about how they see their role. Is it collegial and collaborative as they like to imply with their smooth rhetoric? Or is it to regulate and control as suggested by their stonewalling and unwillingness to engage until they receive petitions from large numbers of angry members?

It will be interesting to see what will unfold as alternatives such as the NBPAS gain traction. It costs $169 to become board certified with the NBPAS.

Ironically, we already have peer review processes in university hospitals and health care systems, which really assess our performance in practice. Most doctors know that you can pass any number of multiple-choice exams and still not practice good medicine. Peer review can be done cheaply and truly reflects our clinical practice. Our British and Australian colleagues have opted for a similar approach with peer groups for mid-career psychiatrists. But one suspects that our boards will not approve activities where they cannot collect fees.

That, sadly, is the state of our MOC process. Hopefully, next year, there will be better news.

We need our own Dr. Tierstein for that to happen. Or maybe we should begin by joining the NBPAS, where he already represents our interests.

Postscript:

I had just finished writing the above article when I received a mass communication from the ABPN dated Feb.19, 2016. While maintaining Part IV of MOC, the board has now given us the option of completing either the Feedback Module or the Clinical Audit Module. So there is progress, although one can’t help wondering why ABPN officials changed their minds after previously insisting how critical the PIP modules were. What they don’t plan to do yet is discontinue the recertification examinations. And not surprisingly, the “approved products.” Ironically, Part IV, if implemented as our U.K. and Australian colleagues have done, would be far more reflective of MOC than examinations, though far less lucrative.

The other piece of good news is that on Feb. 22, we received a survey from the AAGP essentially asking what we thought of the discrepancies in recertification requirements between child and geriatric psychiatrists. Clearly I’m not alone, and implicit in the questions is a concern about geriatric psychiatrists not recertifying. (I wonder why.)

Maybe 2016 will prove to be a good year, after all.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.

It’s been almost a year since I published a lengthy critique of the irrationality and arbitrariness of our current maintenance of certification process. I was concerned that there was no clearly articulated, evidence-based justification for these practices.

This is ironic, precisely because the underlying rationale has been an appeal to the importance of practicing evidence-based medicine. The same does not apply to the maintenance of certification (MOC) process, and therefore, what is preached (or mandated?) isn’t practiced. To date, there is still no definitive study proving that MOC and recertification exams improve physician performance.

I made the point that it made no sense that if public safety were really the main goal of recertification, then no one should be “grandfathered” and all diplomates should have to recertify. MOC should be relevant, affordable, and not onerous. I argued that peer review as practiced at Veterans Affairs hospitals and in English-speaking countries was a far more effective way of reviewing our practice and ensuring patient safety.

I also asked why my recent recertification in geriatric psychiatry, passed with flying colors, would be invalidated unless I recertified in general psychiatry. And I wanted to know why the same did not apply to child and adolescent psychiatrists. My exasperation increased to lorazepam-requiring levels, when I entered a bureaucratic labyrinth of fruitless attempts to obtain rational explanations for these anomalies from superiors in the higher echelons of the American Board of Psychiatry and Neurology (ABPN).

Responses, if I got them, were vague and referred to consensus at meetings by nameless committees. I was advised by one correspondent, who claimed to have been at one of the meetings, that there was to be an announcement in one of the newsletters I receive online from the American Association for Geriatric Psychiatry (AAGP). To date, there has been no mention of the issue, and the person who I was told by another person led the discussion could not recall that this topic had ever been discussed. (I have the correspondence to prove this.) He did cheerfully (I think) tell me that he had written both exams and that the process hadn’t been too onerous. I think he might have been trying to tell me that if he could do it without complaining, then so could everyone else.

Then I actually got to meet Dr. Larry R. Faulkner, the ABPN’s CEO, at last year’s ABPN MOC session at the American Psychiatric Association’s annual meeting in Toronto. I felt a touch of nervousness when I introduced myself as “the person who wrote to ask why the requirements were different.” For all I knew, there might have been others, but Dr. Faulkner’s eyebrows rose in a sort of recognition. We shared a joke about how relieved he was that I didn’t appear deranged. I wondered if perhaps he might have been a little disappointed, as at least he’d then have had the option of calling security.

I was able, in my most diplomatic tone – I am after all, a diplomate of the ABPN – to once again pose the vexed question about why it was that child psychiatrists were not required to maintain their certification in general psychiatry as well. This time, Dr. Faulkner did not defer to some anonymous committee at the AAGP, but said the decision was based on the fact that geriatric psychiatrists are more likely to see adult patients than are child psychiatrists. He regarded me with the assurance you’d expect from someone confident that he’d had the last word. I had no idea of the statistics, which I assumed supported his pronouncement. “I see,” I said. Dr. Faulkner smiled again. Game over.

“I’m a child psychiatrist, and I’d say about 40% of my practice is adult psychiatry” said a man next to me who had been listening to our conversation. Dr. Faulkner frowned.

“I’m a geriatric psychiatrist. I’d say about 10% of my practice is adult psychiatry,” I chirped.

Dr. Faulkner frowned again. He looked at his watch.

“Anyway,” he said.

We looked at him. He shrugged.

“Yeah, well what can you do?” he said.

We shrugged.

“Gotta go; nice meeting you,” he said.

“Yeah,” we agreed.

“I guess he gets lots of complaints,” I said to the child psychiatrist.

“Don’t we all,“ he said.

But I digress. Or maybe not. What does this all have to do with MOC? The whole debate on MOC erupted when Dr. Paul Tierstein, a cardiologist in La Jolla, Calif., organized a petition signed by thousands of internists frustrated by increasingly expensive, onerous, and irrelevant requirements by the American Board of Internal Medicine (ABIM). The ABIM leadership ignored its members, shrugging and equivocating and asserting its will. Once the petition was signed and the anger palpable came apologies and backtracking. Then Kurt Eichenwald of Newsweek got hold of the story. He went on to expose financial malfeasance at the ABIM. The diplomates were paying for the executives’ lavish salaries, bonuses, and perks, including a condo, with their hard-earned recertification fees. It didn’t look good.

The ABPN quickly sent out a statement proclaiming its differences from the ABIM, boasting of greater responsiveness. To prove it, the ABPN even made one of the part IV performance in practice (PIP) modules optional – the one where you get your friends and colleagues to fill in forms and give you excellent performance ratings. No doubt, ABPN officials were afraid of a similar revolt among their own members – who were snarling in the online chat rooms. But ABPN officials weren’t ready to give up – especially the lucrative parts of MOC like recertification exams and their “approved products” for the PIP clinical modules. They continued to assert that only their version of MOC was valid while implying that anyone critical of their approach wasn’t serious about maintaining their expertise.

Dr. Tierstein and his associates created a new board, the National Board of Physicians and Surgeons (NBPAS). More and more hospitals are accepting its certification, which costs much less than the ABMS member boards. Many of us have joined. I suspect more are thinking about it. The NBPAS’ main requirements are previous certification by an ABMS member board and 50 hours of CME in the previous 24 months. If your certification has lapsed, you must have 100 hours. You must be licensed and in good standing. The NBPAS is not a free-for-all but a reasonable alternative to the ABMS.

But the ABPN and other member boards are fighting back. MOC exams are alive, well, and exorbitantly priced. The application fee for the exam is $700 for a form that takes less than 5 minutes to fill in. The exam fee is $700. And the late application fee is an additional $500.

The ABPN recently sent out an enthusiastic memo with a whole new set of tasks to complete, apparently pertaining to patient safety. Who could argue about the importance of that? Except it includes topics like “corporate compliance, the deficit reduction act, infection control, and preventing occupational exposure,” which aren’t always hugely relevant in psychiatry. Anyway, the bureaucrats at the hospitals we work for are equally adept at submitting us to hours of mind-numbing “trainings” in these subjects. Who knows why the ABPN got in on the act as well? Could it be the “approved products” on sale to fulfill these new requirements?

That the ABMS member boards’ main focus is pecuniary is further suggested by the enormous compensation its CEOs and presidents receive. They may not be in the same league as Wall Street investment bankers, but they earn on average two to four times more than the doctors whom they have subjugated under the MOC yoke. For those interested, the following link is instructive. We discover that according to the IRS, our own Dr. Faulkner is well remunerated.

We are unlikely to get answers as long as the ABPN and other member boards issue directives and refuse to engage in meaningful dialogue with their diplomates. It really is about how they see their role. Is it collegial and collaborative as they like to imply with their smooth rhetoric? Or is it to regulate and control as suggested by their stonewalling and unwillingness to engage until they receive petitions from large numbers of angry members?

It will be interesting to see what will unfold as alternatives such as the NBPAS gain traction. It costs $169 to become board certified with the NBPAS.

Ironically, we already have peer review processes in university hospitals and health care systems, which really assess our performance in practice. Most doctors know that you can pass any number of multiple-choice exams and still not practice good medicine. Peer review can be done cheaply and truly reflects our clinical practice. Our British and Australian colleagues have opted for a similar approach with peer groups for mid-career psychiatrists. But one suspects that our boards will not approve activities where they cannot collect fees.

That, sadly, is the state of our MOC process. Hopefully, next year, there will be better news.

We need our own Dr. Tierstein for that to happen. Or maybe we should begin by joining the NBPAS, where he already represents our interests.

Postscript:

I had just finished writing the above article when I received a mass communication from the ABPN dated Feb.19, 2016. While maintaining Part IV of MOC, the board has now given us the option of completing either the Feedback Module or the Clinical Audit Module. So there is progress, although one can’t help wondering why ABPN officials changed their minds after previously insisting how critical the PIP modules were. What they don’t plan to do yet is discontinue the recertification examinations. And not surprisingly, the “approved products.” Ironically, Part IV, if implemented as our U.K. and Australian colleagues have done, would be far more reflective of MOC than examinations, though far less lucrative.

The other piece of good news is that on Feb. 22, we received a survey from the AAGP essentially asking what we thought of the discrepancies in recertification requirements between child and geriatric psychiatrists. Clearly I’m not alone, and implicit in the questions is a concern about geriatric psychiatrists not recertifying. (I wonder why.)

Maybe 2016 will prove to be a good year, after all.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.

Most of us have had nightmares about failing exams we took at school or college. We wake up with a jolt, perspiring – and then have that delicious realization that it was all just a bad dream. We sigh and smile, roll over, and go back to sleep, secure in the knowledge that we are teachers, professors, engineers, lawyers, or doctors, after all.

Wait, did I include doctors? I apologize. Doctors are not included in that group of professionals who can rest easy at night when these dreams assail them. Medical school goes on forever. All the years of dedication to reach a certain level of knowledge and understanding of the body, disease, diagnosis, and treatment appear to have been in vain. For the last 20 years, American doctors alone have been required to take recertification examinations in their respective specialties. Our colleagues in other English-speaking countries shake their heads in bafflement, pity, and relief when they hear about it.

It doesn’t matter that we took more advanced exams in our specialties to get board certified after long and arduous residencies. And we are always attending conferences to keep up.

At first, after a bit of grumbling, we rationalized that maybe it wasn’t such a bad thing, especially as the American Board of Medical Specialties (ABMS) told us it was a way of assuring the public that we kept up to date – and anyway, we had no choice. There was a little disquiet, because these recertification requirements did not apply to everyone.

The older doctors were exempted and aptly called grandfathers. Quite a few people thought it didn’t make sense, because the grandfathers were the least likely to be up to date. How could that possibly be reassuring to the public? But the younger doctors couldn’t do much about it. It was like Animal Farm, where some animals were said to be more equal than others. But it was more mundane than that. An official with the American Board of Psychiatry and Neurology (ABPN) told us at a conference that there were threats of class action suits by the grandfathers and the board didn’t want the expense, which would be passed on to us, anyway.

As the years went by, there were more things we had to do to prove we could do our job of looking after patients, even though most of us were already doing it. The ABMS called these additional duties maintenance of certification, or MOC.

When we were not caring for our patients, we were busy with our MOC, attending more conferences, spending less time with our families and more money on various educational “products.” Ironically, one of the topics we had to study was “physician burnout,” because it could affect patient care. No one said that all these extra tests were one of the major causes of burnout.

Some thought it was a cruel joke and wondered whether MOC was short for mockery. It was all becoming too much, but the ABMS said these new requirements were for the benefit of our patients, and the vast majority of doctors care about their patients, so everyone was afraid to speak out.

Finally, a very brave doctor, Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic at La Jolla, Calif., had had enough. He and his colleagues sent out a petition that nearly 20,000 doctors signed protesting the increasingly burdensome MOC requirements of his board, the ABIM (American Board of Internal Medicine). They formed a group called Physicians for Certification Change, making it clear that they wanted to keep up to date and be good doctors, but they believed that there were other ways to do it. They also pointed out that the ABIM, which said it was very important that everyone practiced evidence-based medicine, had no evidence that the new system made them better doctors. You can read Dr. Teirstein’s fine op-ed.

At first, ABIM board members refused to respond directly to the petition for more than a year. They issued edicts about the importance, validity, and necessity of their MOC process. Then suddenly in January of this year, to everyone’s surprise, Dr. Richard J. Baron, CEO of the ABIM, issued an apology, saying that the board had been wrong, had misjudged the situation, and had been out of touch with the will of the doctors it claimed to represent. The ABIM suspended its plans and price increases as well as its threats to name those not in compliance with its program for a period of 2 years, pending further review. It was as though the ABIM was fearful of a revolt and needed time to regroup.

Dr. Teirstein, who had sent the petition, had created the National Board of Physicians and Surgeons. (Another effort, called Change Board Recertification, is also gaining momentum.)

Within days, our own board, the ABPN, responded to the ABIM’s policy shift. Dr. Larry R. Faulkner, president and CEO, sent an e-mail to all diplomates on Feb. 10, 2015, assuring us all that the changes proposed by the ABIM were already in place at the ABPN, which believed, among other things, that MOC should be collaborative, not onerous. Finally, he proclaimed: “The ABPN is continually looking for more ways to improve its relevance and flexibility and to reduce the burden it places on our busy diplomates. As we have done in the past, we welcome any constructive recommendations in that regard.”

This was all very promising. And so I wrote to Dr. Faulkner to ask whether he could explain why diplomates in geriatric psychiatry were required to maintain their certification in general psychiatry when it was not required of child and adolescent psychiatrists.

The ABPN had told me that even though I recently had recertified in geriatric psychiatry, it would be invalidated if I did not recertify in general psychiatry in a year’s time. Apart from being onerous, this did not seem to be rational, fair, or collaborative. My e-mail went unanswered for a week, so I called the ABPN, and the person with whom I spoke promised to relay my message to Dr. Faulkner.

He responded the next day. It was, he wrote, an “interesting and complex issue,” but the matter had been decided by a consensus of opinion at a forum on crucial issues, although it could be revisited at some unspecified future date. Apparently, representatives of our subspecialty from the American Association for Geriatric Psychiatry (AAGP) had recommended that this policy be maintained, and he suggested that I approach them. I found it hard to believe that all senior members of the AAGP would sign on to such an irrational policy.

This was confirmed by an e-mail I received from the AAGP president, Dr. Susan Schultz, who thanked me for my advocacy and said she had found “very different perspectives” on the matter among members and had therefore arranged for a discussion about it at a meeting at the AAGP conference at the end of March 2015.

I concluded that the decision was not based on evidence, since the forum had breakout sessions at which decisions were based “on the sentiments of very experienced participants,” according to Dr. Faulkner. Even as an AAGP member, I was not aware of these meetings. One of the criticisms of the ABIM was that there was a lack of transparency and involvement by physicians in the whole process. Policy making by “sentiment” is an interesting, if troubling, concept.

Despite the ABPN’s pronouncements, it is not clear that the situation is much better with our own board. To date, I have not received a response to my additional questions regarding the “grandfathering “ issue with its contradictions.

There are still many unanswered questions about MOC. Does it benefit our patients and ourselves, or those who impose it and refuse to engage in meaningful dialogue about its shape, form, and content, not to mention its expense? Ah, the expense. We are fleeced for about $1,500 to sit and answer arcane multiple choice questions for 3 hours in these MOC exams. The aforementioned organizations questioning the MOC process obtained tax returns of the ABMS showing massive increases in revenues from recertification exams in recent years.

And what if we fail? Has the wand been waved to magically transform us from good to bad doctors? The cognitively distorted black and white landscape of multiple choice questions bears little resemblance to the gray reality of patient care where there are often no right answers. But that’s a whole other subject. Or is it?

A final word about our professional grandfathers is in order. If I have seemed harsh, it is only because of the sense of injustice. A more interesting question about the grandfathered generation is whether they were worse doctors without the onerous MOC regime we now all face? We stand, as it is said, on the shoulders of giants who did fine without MOC and recertification. Many critics have said that the boards have simply jumped on the bandwagon of overregulation, citing a faceless “public” that demands more “accountability” – a spurious claim, especially when you consider that to justify “grandfathering,” the boards must defend the paradox that MOC both is and is not necessary to ensure public safety.

As the boards seek to impose MOC on older physicians, many are considering, or are taking, early retirement. Was the ABMS’s intention to eliminate a wealth of clinical experience with MOC? Will our senior clinicians be there long enough to pass on their clinical expertise to the next generation? Can MOC adequately capture and quantify the loss of our older colleagues? They inspired us with dreams and a sense of possibility for our professional lives – even when they were dented by the constraints imposed on us by the insurance industry. Did anyone ever imagine that our own boards would adopt similar tactics?

If we are to sleep well and reclaim our dreams of looking after patients with the best information available, we will, as a group, have to ask these questions and insist on proper answers. But we will need a unified voice.

It took a concerted effort and 20,000 signatures – a grassroots movement – to get a response from the ABIM. Because any criticism of MOC is portrayed as laziness or irresponsibility, rather than a legitimate concern about its methods, there is little doubt that it will take a similar effort in psychiatry.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.

Most of us have had nightmares about failing exams we took at school or college. We wake up with a jolt, perspiring – and then have that delicious realization that it was all just a bad dream. We sigh and smile, roll over, and go back to sleep, secure in the knowledge that we are teachers, professors, engineers, lawyers, or doctors, after all.

Wait, did I include doctors? I apologize. Doctors are not included in that group of professionals who can rest easy at night when these dreams assail them. Medical school goes on forever. All the years of dedication to reach a certain level of knowledge and understanding of the body, disease, diagnosis, and treatment appear to have been in vain. For the last 20 years, American doctors alone have been required to take recertification examinations in their respective specialties. Our colleagues in other English-speaking countries shake their heads in bafflement, pity, and relief when they hear about it.

It doesn’t matter that we took more advanced exams in our specialties to get board certified after long and arduous residencies. And we are always attending conferences to keep up.

At first, after a bit of grumbling, we rationalized that maybe it wasn’t such a bad thing, especially as the American Board of Medical Specialties (ABMS) told us it was a way of assuring the public that we kept up to date – and anyway, we had no choice. There was a little disquiet, because these recertification requirements did not apply to everyone.

The older doctors were exempted and aptly called grandfathers. Quite a few people thought it didn’t make sense, because the grandfathers were the least likely to be up to date. How could that possibly be reassuring to the public? But the younger doctors couldn’t do much about it. It was like Animal Farm, where some animals were said to be more equal than others. But it was more mundane than that. An official with the American Board of Psychiatry and Neurology (ABPN) told us at a conference that there were threats of class action suits by the grandfathers and the board didn’t want the expense, which would be passed on to us, anyway.

As the years went by, there were more things we had to do to prove we could do our job of looking after patients, even though most of us were already doing it. The ABMS called these additional duties maintenance of certification, or MOC.

When we were not caring for our patients, we were busy with our MOC, attending more conferences, spending less time with our families and more money on various educational “products.” Ironically, one of the topics we had to study was “physician burnout,” because it could affect patient care. No one said that all these extra tests were one of the major causes of burnout.

Some thought it was a cruel joke and wondered whether MOC was short for mockery. It was all becoming too much, but the ABMS said these new requirements were for the benefit of our patients, and the vast majority of doctors care about their patients, so everyone was afraid to speak out.

Finally, a very brave doctor, Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic at La Jolla, Calif., had had enough. He and his colleagues sent out a petition that nearly 20,000 doctors signed protesting the increasingly burdensome MOC requirements of his board, the ABIM (American Board of Internal Medicine). They formed a group called Physicians for Certification Change, making it clear that they wanted to keep up to date and be good doctors, but they believed that there were other ways to do it. They also pointed out that the ABIM, which said it was very important that everyone practiced evidence-based medicine, had no evidence that the new system made them better doctors. You can read Dr. Teirstein’s fine op-ed.

At first, ABIM board members refused to respond directly to the petition for more than a year. They issued edicts about the importance, validity, and necessity of their MOC process. Then suddenly in January of this year, to everyone’s surprise, Dr. Richard J. Baron, CEO of the ABIM, issued an apology, saying that the board had been wrong, had misjudged the situation, and had been out of touch with the will of the doctors it claimed to represent. The ABIM suspended its plans and price increases as well as its threats to name those not in compliance with its program for a period of 2 years, pending further review. It was as though the ABIM was fearful of a revolt and needed time to regroup.

Dr. Teirstein, who had sent the petition, had created the National Board of Physicians and Surgeons. (Another effort, called Change Board Recertification, is also gaining momentum.)

Within days, our own board, the ABPN, responded to the ABIM’s policy shift. Dr. Larry R. Faulkner, president and CEO, sent an e-mail to all diplomates on Feb. 10, 2015, assuring us all that the changes proposed by the ABIM were already in place at the ABPN, which believed, among other things, that MOC should be collaborative, not onerous. Finally, he proclaimed: “The ABPN is continually looking for more ways to improve its relevance and flexibility and to reduce the burden it places on our busy diplomates. As we have done in the past, we welcome any constructive recommendations in that regard.”

This was all very promising. And so I wrote to Dr. Faulkner to ask whether he could explain why diplomates in geriatric psychiatry were required to maintain their certification in general psychiatry when it was not required of child and adolescent psychiatrists.

The ABPN had told me that even though I recently had recertified in geriatric psychiatry, it would be invalidated if I did not recertify in general psychiatry in a year’s time. Apart from being onerous, this did not seem to be rational, fair, or collaborative. My e-mail went unanswered for a week, so I called the ABPN, and the person with whom I spoke promised to relay my message to Dr. Faulkner.

He responded the next day. It was, he wrote, an “interesting and complex issue,” but the matter had been decided by a consensus of opinion at a forum on crucial issues, although it could be revisited at some unspecified future date. Apparently, representatives of our subspecialty from the American Association for Geriatric Psychiatry (AAGP) had recommended that this policy be maintained, and he suggested that I approach them. I found it hard to believe that all senior members of the AAGP would sign on to such an irrational policy.

This was confirmed by an e-mail I received from the AAGP president, Dr. Susan Schultz, who thanked me for my advocacy and said she had found “very different perspectives” on the matter among members and had therefore arranged for a discussion about it at a meeting at the AAGP conference at the end of March 2015.

I concluded that the decision was not based on evidence, since the forum had breakout sessions at which decisions were based “on the sentiments of very experienced participants,” according to Dr. Faulkner. Even as an AAGP member, I was not aware of these meetings. One of the criticisms of the ABIM was that there was a lack of transparency and involvement by physicians in the whole process. Policy making by “sentiment” is an interesting, if troubling, concept.

Despite the ABPN’s pronouncements, it is not clear that the situation is much better with our own board. To date, I have not received a response to my additional questions regarding the “grandfathering “ issue with its contradictions.

There are still many unanswered questions about MOC. Does it benefit our patients and ourselves, or those who impose it and refuse to engage in meaningful dialogue about its shape, form, and content, not to mention its expense? Ah, the expense. We are fleeced for about $1,500 to sit and answer arcane multiple choice questions for 3 hours in these MOC exams. The aforementioned organizations questioning the MOC process obtained tax returns of the ABMS showing massive increases in revenues from recertification exams in recent years.

And what if we fail? Has the wand been waved to magically transform us from good to bad doctors? The cognitively distorted black and white landscape of multiple choice questions bears little resemblance to the gray reality of patient care where there are often no right answers. But that’s a whole other subject. Or is it?

A final word about our professional grandfathers is in order. If I have seemed harsh, it is only because of the sense of injustice. A more interesting question about the grandfathered generation is whether they were worse doctors without the onerous MOC regime we now all face? We stand, as it is said, on the shoulders of giants who did fine without MOC and recertification. Many critics have said that the boards have simply jumped on the bandwagon of overregulation, citing a faceless “public” that demands more “accountability” – a spurious claim, especially when you consider that to justify “grandfathering,” the boards must defend the paradox that MOC both is and is not necessary to ensure public safety.

As the boards seek to impose MOC on older physicians, many are considering, or are taking, early retirement. Was the ABMS’s intention to eliminate a wealth of clinical experience with MOC? Will our senior clinicians be there long enough to pass on their clinical expertise to the next generation? Can MOC adequately capture and quantify the loss of our older colleagues? They inspired us with dreams and a sense of possibility for our professional lives – even when they were dented by the constraints imposed on us by the insurance industry. Did anyone ever imagine that our own boards would adopt similar tactics?

If we are to sleep well and reclaim our dreams of looking after patients with the best information available, we will, as a group, have to ask these questions and insist on proper answers. But we will need a unified voice.

It took a concerted effort and 20,000 signatures – a grassroots movement – to get a response from the ABIM. Because any criticism of MOC is portrayed as laziness or irresponsibility, rather than a legitimate concern about its methods, there is little doubt that it will take a similar effort in psychiatry.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.

Most of us have had nightmares about failing exams we took at school or college. We wake up with a jolt, perspiring – and then have that delicious realization that it was all just a bad dream. We sigh and smile, roll over, and go back to sleep, secure in the knowledge that we are teachers, professors, engineers, lawyers, or doctors, after all.

Wait, did I include doctors? I apologize. Doctors are not included in that group of professionals who can rest easy at night when these dreams assail them. Medical school goes on forever. All the years of dedication to reach a certain level of knowledge and understanding of the body, disease, diagnosis, and treatment appear to have been in vain. For the last 20 years, American doctors alone have been required to take recertification examinations in their respective specialties. Our colleagues in other English-speaking countries shake their heads in bafflement, pity, and relief when they hear about it.

It doesn’t matter that we took more advanced exams in our specialties to get board certified after long and arduous residencies. And we are always attending conferences to keep up.

At first, after a bit of grumbling, we rationalized that maybe it wasn’t such a bad thing, especially as the American Board of Medical Specialties (ABMS) told us it was a way of assuring the public that we kept up to date – and anyway, we had no choice. There was a little disquiet, because these recertification requirements did not apply to everyone.

The older doctors were exempted and aptly called grandfathers. Quite a few people thought it didn’t make sense, because the grandfathers were the least likely to be up to date. How could that possibly be reassuring to the public? But the younger doctors couldn’t do much about it. It was like Animal Farm, where some animals were said to be more equal than others. But it was more mundane than that. An official with the American Board of Psychiatry and Neurology (ABPN) told us at a conference that there were threats of class action suits by the grandfathers and the board didn’t want the expense, which would be passed on to us, anyway.

As the years went by, there were more things we had to do to prove we could do our job of looking after patients, even though most of us were already doing it. The ABMS called these additional duties maintenance of certification, or MOC.

When we were not caring for our patients, we were busy with our MOC, attending more conferences, spending less time with our families and more money on various educational “products.” Ironically, one of the topics we had to study was “physician burnout,” because it could affect patient care. No one said that all these extra tests were one of the major causes of burnout.

Some thought it was a cruel joke and wondered whether MOC was short for mockery. It was all becoming too much, but the ABMS said these new requirements were for the benefit of our patients, and the vast majority of doctors care about their patients, so everyone was afraid to speak out.

Finally, a very brave doctor, Paul Teirstein, chief of cardiology and director of interventional cardiology at the Scripps Clinic at La Jolla, Calif., had had enough. He and his colleagues sent out a petition that nearly 20,000 doctors signed protesting the increasingly burdensome MOC requirements of his board, the ABIM (American Board of Internal Medicine). They formed a group called Physicians for Certification Change, making it clear that they wanted to keep up to date and be good doctors, but they believed that there were other ways to do it. They also pointed out that the ABIM, which said it was very important that everyone practiced evidence-based medicine, had no evidence that the new system made them better doctors. You can read Dr. Teirstein’s fine op-ed.

At first, ABIM board members refused to respond directly to the petition for more than a year. They issued edicts about the importance, validity, and necessity of their MOC process. Then suddenly in January of this year, to everyone’s surprise, Dr. Richard J. Baron, CEO of the ABIM, issued an apology, saying that the board had been wrong, had misjudged the situation, and had been out of touch with the will of the doctors it claimed to represent. The ABIM suspended its plans and price increases as well as its threats to name those not in compliance with its program for a period of 2 years, pending further review. It was as though the ABIM was fearful of a revolt and needed time to regroup.

Dr. Teirstein, who had sent the petition, had created the National Board of Physicians and Surgeons. (Another effort, called Change Board Recertification, is also gaining momentum.)

Within days, our own board, the ABPN, responded to the ABIM’s policy shift. Dr. Larry R. Faulkner, president and CEO, sent an e-mail to all diplomates on Feb. 10, 2015, assuring us all that the changes proposed by the ABIM were already in place at the ABPN, which believed, among other things, that MOC should be collaborative, not onerous. Finally, he proclaimed: “The ABPN is continually looking for more ways to improve its relevance and flexibility and to reduce the burden it places on our busy diplomates. As we have done in the past, we welcome any constructive recommendations in that regard.”

This was all very promising. And so I wrote to Dr. Faulkner to ask whether he could explain why diplomates in geriatric psychiatry were required to maintain their certification in general psychiatry when it was not required of child and adolescent psychiatrists.

The ABPN had told me that even though I recently had recertified in geriatric psychiatry, it would be invalidated if I did not recertify in general psychiatry in a year’s time. Apart from being onerous, this did not seem to be rational, fair, or collaborative. My e-mail went unanswered for a week, so I called the ABPN, and the person with whom I spoke promised to relay my message to Dr. Faulkner.

He responded the next day. It was, he wrote, an “interesting and complex issue,” but the matter had been decided by a consensus of opinion at a forum on crucial issues, although it could be revisited at some unspecified future date. Apparently, representatives of our subspecialty from the American Association for Geriatric Psychiatry (AAGP) had recommended that this policy be maintained, and he suggested that I approach them. I found it hard to believe that all senior members of the AAGP would sign on to such an irrational policy.

This was confirmed by an e-mail I received from the AAGP president, Dr. Susan Schultz, who thanked me for my advocacy and said she had found “very different perspectives” on the matter among members and had therefore arranged for a discussion about it at a meeting at the AAGP conference at the end of March 2015.

I concluded that the decision was not based on evidence, since the forum had breakout sessions at which decisions were based “on the sentiments of very experienced participants,” according to Dr. Faulkner. Even as an AAGP member, I was not aware of these meetings. One of the criticisms of the ABIM was that there was a lack of transparency and involvement by physicians in the whole process. Policy making by “sentiment” is an interesting, if troubling, concept.

Despite the ABPN’s pronouncements, it is not clear that the situation is much better with our own board. To date, I have not received a response to my additional questions regarding the “grandfathering “ issue with its contradictions.

There are still many unanswered questions about MOC. Does it benefit our patients and ourselves, or those who impose it and refuse to engage in meaningful dialogue about its shape, form, and content, not to mention its expense? Ah, the expense. We are fleeced for about $1,500 to sit and answer arcane multiple choice questions for 3 hours in these MOC exams. The aforementioned organizations questioning the MOC process obtained tax returns of the ABMS showing massive increases in revenues from recertification exams in recent years.

And what if we fail? Has the wand been waved to magically transform us from good to bad doctors? The cognitively distorted black and white landscape of multiple choice questions bears little resemblance to the gray reality of patient care where there are often no right answers. But that’s a whole other subject. Or is it?

A final word about our professional grandfathers is in order. If I have seemed harsh, it is only because of the sense of injustice. A more interesting question about the grandfathered generation is whether they were worse doctors without the onerous MOC regime we now all face? We stand, as it is said, on the shoulders of giants who did fine without MOC and recertification. Many critics have said that the boards have simply jumped on the bandwagon of overregulation, citing a faceless “public” that demands more “accountability” – a spurious claim, especially when you consider that to justify “grandfathering,” the boards must defend the paradox that MOC both is and is not necessary to ensure public safety.

As the boards seek to impose MOC on older physicians, many are considering, or are taking, early retirement. Was the ABMS’s intention to eliminate a wealth of clinical experience with MOC? Will our senior clinicians be there long enough to pass on their clinical expertise to the next generation? Can MOC adequately capture and quantify the loss of our older colleagues? They inspired us with dreams and a sense of possibility for our professional lives – even when they were dented by the constraints imposed on us by the insurance industry. Did anyone ever imagine that our own boards would adopt similar tactics?

If we are to sleep well and reclaim our dreams of looking after patients with the best information available, we will, as a group, have to ask these questions and insist on proper answers. But we will need a unified voice.

It took a concerted effort and 20,000 signatures – a grassroots movement – to get a response from the ABIM. Because any criticism of MOC is portrayed as laziness or irresponsibility, rather than a legitimate concern about its methods, there is little doubt that it will take a similar effort in psychiatry.

Dr. Rosin is clinical assistant professor of psychiatry at the University of British Columbia and a community geriatric psychiatrist in Vancouver.