In recent years, in order to delineate our specialty and so indicate our unique field of clinical application to outside bodies, we have become increasingly concerned with the issue of certification in psychoanalysis and with the establishment of a board or body whose responsibilities will be the establishment and operation of this certifying process. Various suggestions have been proposed as regards certification in psychoanalysis and various alternatives have been explored, but none seems to be an ideal solution to our complex situation. The many arguments for and against one or another proposal are known to many and they need not be recapitulated here. Instead I wish to raise further questions that must be considered in arriving at a course of action.
In many professions certification signifies that an individual has completed the required education and had sufficient experience in a specified field to warrant the designation of “specialist.” In this country specialty training and certification is a voluntary activity under the sponsorship of non-governmental agencies as compared with licensure, which is a state function. In addition to licensure and specialty certification, some professions are identified through registration. Registration is not the same as licensure, although it serves an equivalent function.
Certification, as we know it from experience with specialty boards, is not the same as performance appraisal or competency evaluation. Certification, as it now operates, is more concerned with the education of an applicant and his ability to demonstrate that he was properly educated and trained. As an assessment of competency refers to an applicant's ability to perform what he or she professes to be able to do, a different order of assessment of current and future performance is required than simply the evaluation of an initial qualifying education. The assessment of competency in psychoanalysis is not an easy task but one that can be done provided that distinctions are made between the issues just noted. Obviously, membership in a professional organization is neither certification nor a competency performance assessment, although there may be some linkage if the group's membership requirements are stringent and require more than an evaluation of educational credentials.
Certification and competency/performance assessment have been instituted primarily for the protection of the public. With reimbursement through third party agencies, the importance of having an initial designation that an individual is adequately trained and experienced becomes a necessity. But the “once and only” designation no longer will suffice. Consumers, third party payers, government
and society are demanding, and rightfully so, that the professed specialist be accountable for his or her professional performance on an ongoing basis. It is the responsibility of the individual clinician, the professional society, and the professional educational facilities to formulate criteria, procedures, methods and to provide well-publicized registries of practitioners who have been judged currently competent to perform their professional duties. If we do not assume responsibility for initiating and implementing these measures, others less capable than ourselves will undertake these tasks and we will be forced to comply with what may be less to our liking and what may be less adequate assessment measures. There is some urgency to this crucial task and responsibility.
Each medical specialty board has approved the principle of recertification and ongoing performance appraisal. Some have already implemented procedures for this purpose. We hear reports of the close linkage between mandatory continuing education and relicensure, recertification, continued membership in professional and specialty societies, continued hospital affiliation and even in obtaining continued malpractice insurance coverage.
If we begin to address the question of professional competency, the issues we must consider, though complex, become clearer. Whether we like it or not, we must begin thinking about and initiating pilot projects that test the feasibility of some of the plans and which address the crucial questions already asked or soon to be asked. We are responsible and we are accountable.
In 1973, the Committee on Certification in Child Psychiatry of the American Board of Psychiatry and Neurology, and the Center for Educational Development of the University of Illinois College of Medicine initiated a joint study for the purpose of: “(1) developing more valid and reliable procedures for certifying competence in child psychiatry; (2) generating data that would be of assistance to training directors in increasing the efficacy and effectiveness of residency programs in this field; and (3) serving as a pilot for a larger study in general psychiatry to be initiated subsequently by the American Board of Psychiatry and Neurology.” The report of this study has just been published and is entitled Roles and Functions of Child Psychiatrists. Although addressing itself specifically to child psychiatric certification, many of its findings can be used as initial models for our own deliberations.
This article does not intend to review the relatively brief report in detail. I will, however, mention the three parts of the report and their component chapter headings which I believe bear upon our own specialty:
Competence in Patient Care Roles
Skill in Gathering Information
Skill in Formulating a Differential Diagnosis
Skill in Therapeutic Planning
Skill in Therapeutic Management
Skill in Recording Information
Competence in Non-Clinical Roles
Skill in Consultation Skill in Administration
Skill in Evaluating Research
Skill in Teaching
Professional Habits and Attitudes
Ethical Behavior in the Practice of Child Psychiatry
The essential knowledge needed for each of these skills is simply, clearly and concisely stated in the report, as are suggestions for the evaluation of these competencies. Not only does this report address itself to ongoing competency assessment and performance evaluation beyond residency completion, but it pinpoints what a practitioner should know and should learn in continuing programs.
I have not addressed the question of regular, frequent, systematic monitoring of our educational institutions and their continuing education programs. The issue of accreditation of institutes, though related to, is different from the ongoing certification of competency of the individual practitioner. The primary education, as well as the continuing education for individual professional competence, requires internal as well as external control. External control-relicensure, peer review and P.S.R.O. is now a government prerogative.
Psychoanalytic education and clinical experience is a life-long pursuit. No longer will it be solely the individual's responsibility to maintain and verify his professional competency. In today's world evidence and proof of this pursuit will be required. If we now undertake the task at hand and establish our own standards, we will demonstrate our interest and willingness to do so and possibly avoid later complications and hardships.
The profession of psychoanalysis and its educational and continuing education facilities should begin to prepare a similar study to that published by the Committee on Certification in Child Psychiatry. This is where our energies and resources should be focused at this time. The formal labels of certification and the machinery whereby one gets such a designation should come later, after we have established our competency criteria and the means of assessing these on an ongoing basis for all who wish to be k110wn as clinical psychoanalysts. We can do the job that is so essential if we keep our goals and priorities clearly in mind.
—George H. Pollock