The American Medical Association endorsed a resolution in 1867 to secure legislation that would require all persons who wished to practice medicine to be examined by the State Board of Medical Examiners in order to become licensed to practice medicine. Licensure was a requirement, and hence mandatory. The American Board of Medical Specialties (ABMS) was established 60 years later, representing 24 medical specialties, including the American Board of Psychiatry and Neurology. ABMS is the largest physician-led specialty certification organization in the United States. In contrast to licensure, certification has been voluntary, signifying academic achievement. Certification has never been considered a legal requirement to practice medicine.
Psychoanalysts, who are M.D.s and D.O.s, will be particularly affected by the alliance between the Federation of State Medical Boards (FSMB) and (ABMS). In 2002, these separate organizations began a collaboration that embraced the goal of “life-long learning,” a program promoting “excellence in medical practice” through Maintenance of Certification (MOC) and Maintenance of Licensure (MOL). Similar to Continuing Medical Education (CME), the process of certification began as voluntary, but now threatens to become a requirement of licensure.
FSMB comprises 70 state medical and osteopathic boards. FSMB's long-standing mission has been to protect patients from unlawful, unethical, and incompetent doctors. Having received recommendations from ABMS, FSMB will be implementing a new, expanded MOL on a trial basis in 12 states over the next decade. According to the MOL Overview web page, “MOL provides a needed alternative to our current system, offering a framework that requires physicians to demonstrate skills and knowledge in their areas of practice on an ongoing basis—throughout their careers.” (See: )
Reflective self-evaluation, self-assessment, and practice assessment through continuing medical education. Unlike current CME requirements, educational activities will be tailored to meet the needs or deficiencies identified by an assessment of skills.
Demonstrate competence in medical knowledge, patient care, practice-based learning, and interpersonal communication skills.
Demonstrate accountability for performance in practice. Demonstrate application of quality improvement methodologies to clinical practice. Licensees will be held accountable for meeting MOL requirements to renew their licenses.
Approximately 80 percent of physicians are currently certified in at least one medical specialty. ABMS has recommended that state boards accept certification as proof of, or in lieu of, compliance with components 2 and 3 of the new MOL. If state boards accept that recommendation, then certified physicians will be considered to be substantially in compliance with components 2 and 3, without having to perform “demonstrations” called for in those components.
Even though most physicians are certified, there remain approximately 200,000 physicians in the United States who are not board certified. For those physicians (including some renowned psychoanalysts) there may be difficulties in achieving compliance with
Graham L. Spruiell, M.D., is co-chair of the Committee on Government Relations and Insurance and a member of the Program in Psychiatry and the Law, Beth Israel Deaconess Medical Center, Boston.
components 2 and 3. It is not yet clearly spelled out, but it appears that state boards will create an alternate route for maintenance of licensure, other than certification, whereby uncertified physicians can achieve compliance with components 2 and 3 by working through state boards. ABMS may be involved in such activities, but has stated that there may be issues about the confidentiality of physicians' test scores, and the costs of compliance of an alternate pathway for licensure are estimated to be greater than costs associated with MOC. Thus, when MOC/MOL is fully implemented, MOC will effectively become the path of least resistance to maintain licensure.
Physicians-psychoanalysts who are not certified will face a dilemma. They can either sign up to get certified and then recertified every 10 years, with numerous time-consuming and costly steps along the way; or they can work within the MOL framework of state boards, sacrifice privacy of test scores, and pay even higher fees.
ABMS recommends that physicians, who were granted lifetime certification prior to its 10-year recertification rule, should be exempted from MOL, components 2 and 3. ABMS nevertheless strongly encourages those physicians to participate in MOC/MOL and promises that even if they fail the recertification exam, they will not lose their lifetime certifications. Regardless of what ABMS and state boards decide, eventually credentialing offices and state boards may take it upon themselves to require participation in MOC/MOL in order to grant privileges to physicians. This will have a direct and immediate effect on physicians who practice in hospital settings or serve on insurance panels, both of which generally require board certification (and consequently will also require maintenance of certication).
Whatever the implications are for all psychoanalysts, FSMB's new MOC/MOL is unprecedented and should be considered a violation of physician boundaries, because it radically redefines physician competency. Instead of being a function of acquired education and experience, and presumed on that basis, competency under the new MOL is redefined in terms of compliance with (and submission to) an array of practitioner protocols prescribed by MOL. Instead of being presumed competent, such that the state boards must demonstrate that a physician is incompetent or has engaged in misconduct, every physician will be required to demonstrate evidence of “competency,” continuously, by meeting whatever metrics state boards establish for components 2 and 3. Instead of “excellence of medical practice” being a function of the expertise and the conscience of the physician in the context of the physician-patient relationship, excellence of medical practice will come to mean compliance with MOC/MOL.
ABMS has, from the beginning, assured subscribers that certification would be voluntary and that life-long certification would be honored, as promised. ABMS continues to maintain that certification will be voluntary and life-long certification will be recognized, at least by ABMS; yet its alliance with FSMB regarding MOC/MOL could effectively violate both agreements with its subscribers.
The “transformation of health care” may entail the new MOC/MOL, as FSMB asserts. The American Medical Association, American Psychiatric Association, and many other physician-led organizations, along with accreditors and credentialing agencies, all agree and support the proposed MOC/MOL. (It is worth noting that the American Psychiatric Association supports MOC/MOL despite a referendum in which 80 percent of the voting membership objected.) The integrity of the physician's role in the physician-patient relationship constitutes the essential core of medical practice, and it is an unfortunate fact that our changing health care system increasingly creates tension between that core and the exigencies of the system itself.
Just as the Committee on Governmental Affairs and Insurance (CGRI) advocates for preservation of patient consent for disclosure of protected health information, so we are obliged to advocate preserving physician consent regarding certification, and to protect the boundaries of the physician, patient, and physician-patient relationship. We believe that these boundaries may be compromised under the new MOC/MOL. If physicians are unwilling or unable to defend their own rights and ethical principles from being redefined by third parties, including the government, can we protect our patients' rights?
APsaA will be joining forces with other groups and organizations to oppose efforts by third parties to link certification (which should remain voluntary) with licensure (which is a requirement); and to resist efforts that attempt to radically redefine professional ethics, competency, and the agency of health care professionals.