7 minute read
APA Trustee Board Report
Kenneth M. Certa, MD, DLFAPA
There are several issues which APA has had to deal with over the past year. Three contentious items dominated discussion at the March board meeting, again: institutional racism, the budget, and our relationship with the American Board of Psychiatry and Neurology. I hope that anyone reading this will keep in mind that our organization is exactly that—OUR organization. As a board member I recognize the responsibility to keep the organization faithful to its mission, and attentive to the wishes of its members. The decisions facing us, and really all organized medicine, are complex, and I hope that the current impulse to demonize others in the discussion is put on hold for a bit.
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Racism is real, pervasive, and commonly unrecognized. We in psychiatry know well how our early upbringing influences us in so many ways. When I was a child, my family (generally decent, loving, generous people) frequently spoke of Black people in ways which make me cringe to remember. I try hard to see how this still influences me, and read and participate in whatever workshops I can, but there is no doubt some of this persists. This hit home after the events of January 6, when the natural conclusions of white supremacy were on display; fragile white men were literally up in arms as the nation tries to move on to a more inclusive community. Recognizing this reality, the APA board has struggled with how to address the effects of racism within APA and the country. The Task Force on Structural Racism has come up with a series of recommendations which the board voted on, trying to increase involvement of under-represented groups. Term limits in components is one effort, so that there are more open slots for newer members, with explicit efforts to reach out to groups not currently represented. The elections committee has proposed, and the Board approved, piloting changes in election procedures to level the playing field to try to be more inclusive. The biggest change is to limit election activities only to those sanctioned by the election committee itself, making it a violation to use listservs of other organizations. There is some worry that this will drive down election participation to even lower levels (fewer than 20% of members voted this cycle) but we will see. APA’s budget is a continual challenge and impacts our members very directly in both the services provided and the dues charged. So many members and former members post online, and tell me directly, that they are not sure that they get anything for their dues money. So much of what APA does benefits all psychiatrists, really all society, and so there is no convenient divide between members and non-members. We will still fight for better reimbursement for psychiatrists, for clearer confidentiality rules, for careful management of scope of practice, for parity of coverage for mental illness and substance use disorders— whether a particular person joins or leaves. The pandemic has contributed to a reversal of our year-over-year membership gains— down 3.6% last year. Practices are hurting, as patients lose their jobs and watch expenses. Not having an in-person annual meeting two years in a row has contributed to losing people who take advantage of the member discount. Losing the meetings also blows a hole in our budget by itself, since they are a reliable source of income. Costs are down in some areas, since virtual component, Assembly, and Board meetings are much less expensive, which is the only way we can keep a reasonably balanced budget. Budget concerns also play a role in one of our more difficult discussions, the relationship between APA and the American Board of Psychiatry and Neurology. If there were easy solutions to this, they would have been followed a long time ago. It is many layers, with a lot of things mixed up which I will try to tease apart. Even before the Maintenance of Certification wars, there was dissatisfaction with ABPN. It is high-handed, costly, and of uncertain meaning. Board certification itself is much debated but is considered a necessary part of a self-regulating specialty. Without some certification process, it is not clear how one could prevent other physicians from styling themselves as practicing a particular specialty competently. Which board can certify in which specialty has been a work in progress, and at this point the winner has been the American Board of Medical Specialties, a group to which ABPN belongs (along with nearly all of the other major specialty boards)? ABMS is where MOC started many years ago, and several of the other specialties are quite happy with it; procedure-oriented specialties appreciate having a method to demonstrate continued competence. One of the many issues is whether the ABMS one-size-fits-all (some wiggle room for individual boards, but not much) serves specialties like ours. ABMS is poised to issue new requirements for its member boards this spring, and it is expected they will be even more problematic for psychiatry. There is no agreement on whether board certification denotes minimal competency, or a higher standard. And there is very little in the way of outcomes research, showing that psychiatrists who are board certified have better outcomes. (That we still have no great outcomes measures to look at is a big part of this problem.) With all this, board certification was sort of grudgingly accepted so long as it was a one-time thing. When the time-limited certificates came into being (nine years after I certified) there was a hue and cry about differences in practice, sub-specialization, and how the exam could be fair to all. Very few failed, unlike in internal medicine, whose diplomates rose up and started the revolution against continuing certification. MOC was mandated by the ABMS, and initially had very objectionable requirements (remember the patient questionnaire mandate)?
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Through APA’s efforts with ABPN, we have been able to make much of MOC far more palatable. The pilot project, reading among a choice of articles and answering questions, rather than the secure exam, is the best example. I do not think that would have happened without APA’s work. The whole process remains cumbersome, complicated, and costly, as a recent survey of our members demonstrated (awaiting publication in peer-reviewed journal, to carry more weight). What APA members, and psychiatrists in general must ask, is whether our specialty is prepared to go it alone and cut ties with the ABMS monopoly? No question, power tends to corrupt, and absolute power corrupts absolutely. Without an alternative, we are beholding to the ABMS/ABPN. An alternative certification system, the National Board of Physicians and Surgeons, is trying to get established to challenge this, but even they require initial certification by an ABMS board. NBPAS certification accepts the initial certification, and then continues certification if the physician maintains license and documents CME (back to the pre-MOC way). It is only accepted at 138 hospitals (more than 6000 in US), unclear how many insurance companies, and so is uncertain. And for those who let their certification through ABPN/ABMS lapse, starting over means really starting over. APA, AMA and other specialties are united in opposing board certification requirements as a condition of hospital privileges, insurance empaneling, or licensure. But our opposition only goes so far; most hospitals want to see the board certification. Should APA try to take over the whole board certification process, or at least the MOC part? Exploring the legal, ethical, and financial aspects of this is one of the things that the Board voted to approve at the March meeting. There is more on the APA website about the actions being taken regarding MOC here. One serious issue for which there is no good answer, is whether APA should accept unrestricted educational grants from ABPN. The arguments generally are whether this should be seen as APA recouping money that psychiatrists paid too much of already, to serve the profession; or that it is a bribe to keep APA in line to not oppose ABPN too much. The amount of money is substantial and returning what has been given (as some have suggested) would require either significant program cuts, or significant dues increase. There is no unambiguous right answer; increased dues will cost memberships, cutting services could be harmful to the organization and profession, yet there is worry about the conflict of interest. In preparation for the meeting, I asked as many groups as I could about their opinions and got many different answers (including some who thought ABPN should give us much more). The board voted to keep the money, accept more this year, while at the same time exploring ways for APA to potentially enter to board certification business.
