Recredentialing Physicians in New York State and Its Implications for American Psychoanalysis

Medical psychoanalysts throughout the United States may soon have to demonstrate their competence to practice their specialty if a proposed system of physician recredentialing is instituted in New York State. If recredentialing is established there, it is likely that other states will follow suit. Some background information will help in the understanding of this development.

As a result of a surge in medical consumerism and the passage of malpractice reform legislation in 1985 by the New York State Legislature, in May 1986 Governor Cuomo announced his intention to require physicians practicing in New York State to have their credentials recertified periodically as a prerequisite to renewal of their licenses. The aim of recredentialing is to ensure the quality of medical care and to prevent medical errors. The Governor's goal of having recredentialing procedures in place by 1991, however, may be delayed if legislative action is necessary to implement his proposal. Although in its April 18, 1976, Position Paper on Physician Recredentialing the Medical Society of the State of New York vehemently stated its objections to this plan, measures are nevertheless being taken by the State Department of Health to establish it.

The New York State Advisory Committee on Medical Recredentialing was appointed by the State Department of Health and the Board of Regents of the Department of Education to prepare recommendations for the criteria to be met and the process for implementation. This committee, which is cochaired by Alfred Gellhorn, Director of Medical Affairs of the New York State Department of Health, and Martin Cherkasky, Representative of the Board of Regents and Acting President of the New York Academy of Medicine, submitted the report of the first phase of its efforts in January 1988. Its major points are these:

Whether or not a physician's current practice of medicine meets appropriate standards will be determined by peer review rather than by governmental review. Every nine years, office-based physicians (under which category most medical psychoanalysts fall) will be required to demonstrate their professional competence in one of the following ways: (1) by becoming certified in the appropriate specialty board or recertified if already certified; (2) by passing a cognitive, clinically oriented, written examination; or (3) by undergoing a peer review of clinical office records. Hospital-based physicians will have different options available to them.

Should one fail to prove one's professional capability in one of these three ways, educational enrichment or remediation would be required; then another opportunity to demonstrate one's adequacy would be made available. Renewal of one's medical license would ultimately depend on this confirmation of one's professional ability. These three mechanisms for recredentialing present certain problems for psychoanalysts and other psychiatrists. For example, in exercising the first option—board certification or recertification—medical psychoanalysts who are not already certified by the American Board of Psychiatry and Neurology could choose to take the Board examination. Those who are already Board certified, however, do not have the opportunity to become recertified because the American Board of Psychiatry and Neurology has no recertification process in place.

Last year, the Board indicated its willingness to devise an examination for the voluntary recertification of psychiatrists. This examination would be similar to the one given for initial certification in psychiatry (Part I) with the basic science questions removed, thus creating an examination of clinical psychiatry only. A timetable for the development of this recertification examination has not been announced.

The second option—a cognitive examination of clinical knowledge and problem-solving ability—was initially envisioned as having as its subject the entire field of general medicine—a formidable challenge to most practicing psychiatrists. We now understand that the successful completion of the Psychiatric Knowledge and Skills Self–Assessment Program (PKSAP) of the American Psychiatric Association's Office of Education would be an acceptable alternative. This method has been strongly endorsed by the Committee on Peer Review of the American Psychoanalytic Association. PKSAP is a home study program designed to bring psychiatrists up to date on 15 topics in the field. Subscribers receive a collection of readings chosen by respected authorities, multiple choice questions for each topic, and patient management problems. As it now is used for continuing medical education, participants learn at their own pace in their homes or offices, and answers are submitted to the APA for scoring. A follow-up critique and evaluation with extensive feedback on each question are provided. Confidentiality is ensured through an individual coding assignment. It is anticipated that to qualify as a recredentialing method, the PKSAP examination would be taken under proctored circumstances rather than privately as an “open book” examination.

The third choice, review of office records by a committee of peers, was initially presented as a review of randomly selected office records. Because of the need for confidentiality, though, this method was opposed by the Committee on Peer Review and by others as being grossly inappropriate. Consequently, the initial proposal has been modified, and it now appears that psychoanalysts who choose this method will be sent forms to be completed with information about a case selected by the analyst.

The forms will be very similar to those now being used for peer review of psychoanalysis under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and the identity of analysands will be disguised in them. Members of the American may be familiar with this extensive form, which has been published in the APA Peer Review Manual

After the forms are returned to the recredentialing authority, an interview will be scheduled in the analyst's office with two psychoanalytic examiners to discuss the material submitted. The reviewers will be psychoanalysts from a geographic area other than the one in which the clinician works, and the interview will follow a standardized format. The examiners will render a judgment

either that the psychoanalyst merits recredentialing or, in what is expected to be a small number of cases, that educational enrichment is required before recredentialing, probably through successful completion of the APA's PKSAP.

Even with this modification in the procedure, the American's Committee on Peer Review has expressed grave doubts about the wisdom of analysts choosing the third alternative. The Committee members believe that the confidentiality of analysands' communications would still be severely compromised and that the need to obtain analysands' informed consent about the review by a third party would so alter the analysis as to make it virtually impossible for it to proceed successfully. At the urging of Sheila Hafter Gray, Chair of the Committee on Peer Review, the Executive Council of the American voted last December to encourage its members to use the PKSAP alternative for recredentialing. It is the Peer Review Committee's opinion that by using the PKSAP option, analysts will not only protect their cases from scrutiny by reviewers outside the analytic process, but also acquire valuable information about developments in psychiatry.

Because the written reports for peer review of psychoanalytic cases will probably be lengthy and therefore require a great deal of time to prepare, those psychoanalysts whose practices include psychotherapy, pharmacotherapy, and other modalities may prefer to submit nonanalytic cases for review by nonanalysts. The forms for these cases will be shorter and similar to the CHAMPUS Psychiatric Treatment Reports with which many members of the American are familiar.

Dr. Aaron Satloff of Pittsford, New York, Vice-Chair of the APA's Quality Assurance Committee, has been negotiating the changes in New York's proposed recredentialing procedures for psychiatrists with Dr. Gellhorn of the State Department of Health. Though he is not a psychoanalyst, Dr. Satloff is sensitive to the particular needs of psychoanalysts in this difficult area and has been able to communicate them effectively to Dr. Gellhorn. Recently, Dr. Satloff offered to conduct a field trial of the third, office-based peer review option, using volunteer psychiatrists and analysts in New York City and Rochester. However it is not expected to be carried out soon.

Nevertheless, in view of the steady, nationwide movement toward accountability and regulation of medical practice in recent years, some form of physician recredentialing will likely become part of the professional lives of most of the members of the American, if not by 1991, as Goveror Cuomo hopes, then certainly in the not too distant future. The situation in New York State warrants continued monitoring for its potential impact on the psychoanalytic community.