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Most residents have a very limited understanding of the American Board of Psychiatry and Neurology (ABPN), and understandably so.
I myself thought of the ABPN as a large, bureaucratic, governmental organization that spent most of its time siphoning money from hapless residents in order to administer board certification examinations. I was therefore surprised, and a bit skeptical, when my chairman asked me if I was interested in a three-month administrative fellowship at the ABPN during my final year of neurology residency. Although I had an interest in administration, I was hesitant because I was unfamiliar with the fellowship’s objectives, because it would be the first year it was offered.
Three weeks before my administrative fellowship was to begin, a thick binder arrived containing a detailed, day-by-day schedule and multiple articles including, 10 Most Common Mistakes Made by Administrators and Understanding Financial Statements of Not-for Profits. I also received three books on self-improvement: Drive, Talent is Overrated, and, ironically, Being Wrong. Reviewing the schedule, I was surprised to see that I would be spending, collectively, almost four weeks traveling (including internationally).
The binder clearly spelled out the objectives of the fellowship. I was expected to learn about the mission and structure of the ABPN as a whole, and in particular the fiduciary responsibilities of the board of directors. I was to have scheduled meetings with the senior staff to appreciate their role in the day-to-day workings of the ABPN. In addition, I was expected to complete a research project, suitable for submission for presentation and publication. Finally, I was to have weekly meetings with Dr. Larry Faulkner, the President and CEO of the ABPN. It would be these weekly meetings that I would find most useful, as they provided perhaps the greatest educational value of the entire fellowship.
About the ABPN
Prior to my arrival at the ABPN, I learned that it had been formed by psychiatrists and neurologists in 1934 in order to distinguish qualified specialists from those offering neurological or psychiatric care without adequate experience or training.
Rather than a large, bureaucratic organization, the ABPN is relatively small. It consists of less than 40 staff, of which only one is a salaried physician (Dr. Faulkner). The ABPN sitting directors essentially volunteer their time. I quickly learned that the ABPN does not have members (unlike the American Academy of Neurology (AAN) or the American Psychiatric Association) and is an organization that is primarily responsible to the American public. Its main mission is to ensure the public that ABPN diplomates are competent to practice neurology and psychiatry. It does this by first certifying candidates who have graduated from accredited residency programs and by developing methods to assess that practicing physicians continuously keep up with the rapid pace of medical advancement. Initial certification for neurologists and psychiatrists now consists of a computer based examination.
Interestingly, the ABPN is also a driving force behind residency education. Recently, the Accreditation Council of Graduate Medical Education (ACGME) decided that it would not accredit additional combined training programs. Instead of dissolving these programs (in which almost 200 residents are currently enrolled), the ABPN decided to review and approve these combined training programs which include neurology-internal medicine and neurology-psychiatry. While the ACGME establishes minimal requirements for neurology and psychiatry residency programs, the ABPN establishes the necessary pre-requisites a resident must have in order to be eligible to become board certified. Often the ACGME follows suit. For example, initially there was no ACGME requirement that a graduating neurology resident see a single critical care patient. The ABPN determined that an intensive care unit (ICU) clinical skill examination (CSE) would be required in order to apply for an initial board certification exam. Shortly thereafter, the ACGME adopted the ICU CSE as a requirement for residency accreditation.
A recent focus of the ABPN is supporting education and research activities of academic faculty. Given the increasing clinical demands on faculty, I noted that the ABPN grants for innovative education projects placed particular emphasis on ensuring that faculty had protected time to complete those activities. The ABPN will shortly begin another grant program to support research on issues relevant to its mission. In both of the ABPN grant programs, awardees are selected by panels of neurologists and psychiatrists that includes members from within the academic community with established expertise in education or research.
Crucial Issue Forums
The ABPN has also begun to host a yearly “Crucial Issue Forum”. These Forums focus on pressing issues central to the fields of neurology and psychiatry and are used to obtain feedback from professional organizations and others on those issues. Experts in the field, including program directors, department chairs, representatives of national professional organizations, residents, and fellows are invited.
The most recent Forum focused on residency education, and included a discussion about whether the process of the CSEs should be modified to produce a more meaningful educational experience. A growing body of literature has suggested that the CSEs are not as effective as they might be. These sentiments were echoed by several residents, including myself. After attending this Forum, it became clear to me how seriously the ABPN took this Forum. Had the attendees of the Forum voted for the ABPN to conduct site visits to monitor the CSEs at every institution, it is likely that we would have site visits. Conversely, if a clear consensus had been to abolish the CSEs, it is likely that they would no longer exist.
A requirement of the fellowship is a research project with the expectation of publication. Several opportunities exist towards this end, including use of the ABPN’s wealth of data on their initial certification examinations, maintenance of certification exam and CSEs. Given my preexisting interest in both headache and education I surveyed adult neurology residency program directors and chief residents to determine their views on the appropriate amount of headache education in neurology residency. The goal of this project was to determine if headache education had significantly increased from a decade ago when a similar survey had been done. I had the opportunity to present the results to the senior staff of the ABPN as well as at the American Headache Society Annual Scientific Meeting in June 2015. The manuscript was accepted for publication in Headache, The Journal of Head and Face Pain.
The most memorable moments of my fellowship were spent in Dr. Faulkner’s office for our weekly 10 o’clock meetings. These ‘one on one’ meetings typically lasted between 1-2 hours. Rarely was there a set agenda. We discussed everything from Dr. Faulkner’s top ten rules for financial investment, to the inexact science of hiring employees. We talked about the slim evidence base behind maintenance of certification (MOC) and the impetus to have an MOC program despite the lack of strong evidence. We explored why continuing medical education (CME) has not met the same opposition as MOC Part IV, despite the fact that CME is the most time intensive component of MOC.
Behind the backdrop of the formal curriculum, readings, and scheduled meetings, a large part of the fellowship consisted of informal education. Every moment of downtime with Dr. Faulkner was an opportunity for me to learn about the process of becoming a successful administrator. While we waited for our flights we would often talk about everything from family to how important it is to take care of oneself physically and mentally. As Dr. Faulkner put it, “If you fall apart, everything falls apart. If you’re not healthy, you won’t be able to fulfill your family, social, or work responsibilities.” He impressed upon me the importance of being on the same page as one’s spouse and family. We discussed the value of doing a few tasks, but doing them well. I understand now that the real value of this unique experience truly lay in the in-depth immersion that I had into all things administrative, from the ABPN, to academic departments, to professional organizations, and even to my family.
Finally, the fellowship gave me the opportunity to meet with some of the most influential leaders in neurology and psychiatry. It was eye-opening to see the work that goes on behind the scenes at organizations like the AAN, APA, and ACGME. Despite their different responsibilities, each of these national organizations and their respective leaders had the singular goal of furthering the fields of neurology and psychiatry through focused initiatives. I began to appreciate the extraordinary effort that went into the large annual professional meetings. I spent a day at the AAN in Minneapolis learning about their different sections and the spectrum of resources they provide for their members. It was humbling to realize that I could probably spend my whole life on the AAN website and still not be able to take advantage of all the resources they have to offer.
In the ABPN I found an organization that not only tried to uphold the standards that make our profession credible, but also an organization that was dedicated towards the advancement of neurology and psychiatry education. In Dr. Faulkner I found a leader who tried to be fair. He cultivated the potential of those around him into a kinetic energy that translated into a collective success. Much of his time was spent advocating for the best interests of neurologists and psychiatrists against those who would like to propose greater physician scrutiny and regulation.
The mounting pressures of lower reimbursement in the setting of higher patient volumes, the oft-repeated mantra of ‘Do more with less’, and the overwhelming paperwork often overshadow our initial motivation to become physicians. More than anything else, my time at the ABPN and my interaction with the leaders in neurology and psychiatry have given me hope and optimism that we can find our way through the pressured maze of bureaucracy and increasing scrutiny to an era where we will be able to provide the best care for our patients while seamlessly documenting the quality of our work. There are multiple initiatives towards this end, not the least of which is the commitment and support of leaders in neurology to the AAN Axon Registry. In summary, my experience at the ABPN taught me that our future is in our hands and that our collective involvement and effort will be crucial to effectuate the outcomes we desire.
Aminoff, MJ. Faulkner RF. (2012). The American Board of Psychiatry and Neurology, Looking Back and Moving Ahead. Arlington, VA: American Psychiatric Publishing.
Kay, Jerald. (1999(. Administrative Mistakes Handbook of Psychiatric Education and Faculty Development. Washington D.C., American Psychiatric Press.
Schuh, L., London, Z., Neel, R., Brock, C., Kissela, B., Schultz, L., & Gelb, D. (2009). Education Research: Bias and poor interrater reliability in evaluating the neurology clinical skills examination Neurology, 73 (11), 904-908 DOI: 10.1212/WNL.0b013e3181b35212
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