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News and Views Viewpoints and Opinions |
ON MANDATORY CONTINUING EDUCATION |
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In March 2000, the Michigan Board of Psychology (commonly known as the licensing board) unanimously passed a proposal for mandatory continuing education. The proposal is now under consideration by the Engler administration. This article was written with the goal of informing readers about the proposal and about arguments for and against the adoption of mandatory continuing education (CE). BACKGROUND The trend toward mandatory continuing education legislation for psychologists began in the post-Vietnam, post-Watergate environment of the late 1970s. At that time, there was a widespread demand for public scrutiny of and accountability from many institutions that had once enjoyed a privacy based on deference. The professions were among these institutions. A 1976 article in Business Week (quoted in the 1994 APA "Study of Mandatory Continuing Education") summed up the reasons for the increased regulation of the professions: In a sense, the gap between what the professions can deliver and what the public expects them to deliver results from two trends beyond their control: technological complexity and egalitarianism. Both trends are forcing a thoroughgoing reassessment of how well professionals do their jobs and a redefining of what it is they do. The outcome of that reassessment will have great impact not only on professionals, but on society as well. Historically, CE for health care professionals was instituted with the idea that medical knowledge changes so rapidly that it is necessary to protect the public by requiring practitioners to show proof that they are keeping up in some way with cutting-edge technology and skills. CE for clinical psychologists was modeled after similar requirements for pharmacists, physicians, nurses, chiropractors, dentists, and other licensed health-care professionals. THE MICHIGAN PROPOSAL In April 1999, the Michigan Psychological Association (MPA) wrote a position paper supporting the establishment of CE requirements for Michigan psychologists. It says that 43 (83 percent) of the states have already adopted some form of CE requirement for licensure. Requirements range from 10 to 50 CE credit hours per year with an average of 18.9 hours. The MPA position paper recommended that the Board of Psychology adopt CE requirements; that applicants for licensure be responsible for maintaining records of their CE attendance; and that the Board request verification of CE attendance records at the time of license renewal applications. Jack Haynes, Ph.D., Chair of the three-member Rules Committee of the Michigan Board of Psychology, was in charge of writing the mandatory CE proposal that was passed by the Board in March 2000. The proposal states that psychologists should be required to earn 40 CE credits (at a standard ratio of one hour of credit to one hour of educational activity) over a two-year licensing cycle. If the Engler administration approves the proposal, there will be a public hearing so that the Board can hear from psychologists before deciding the specifics of how the plan would be implemented. For example, it is yet to be decided what kinds of activities would be allowed as part of fulfilling the CE requirement. Some states allow licensees to include activities as varied as journal reading, consultation, providing or receiving supervision, teaching a psychology class, personal psychotherapy, serving as an officer in a professional organization, conducting a research project, publishing a paper, or preparation for board exams as part of fulfilling their CE requirements. The Michigan Board has not decided what categories of CE would be allowed under a Michigan requirement, but Dr. Haynes emphasized the Board’s view that procedures should be as simple as possible, noting that, if activities are not documented, the Board has no way of knowing whether an individual psychologist has actually done what he or she says he has done with regard to CE. (In most venues, the simplest way for Boards to check on licensees’ compliance is through certificates of attendance at approved programs and conferences.) The Board has reportedly also expressed a strong interest in requiring some proportion of the required credits to be earned in connection with programs on professional ethics. (The APA’s office of Continuing Professional Education says that thirteen states currently require ethics-specific programs as part of their CE requirements.) The Board’s interest in ethics education is attributed to the fact that psychologists brought before the Board on complaints from the public frequently say they are unfamiliar with the terms of the APA ethics code. Dr. Haynes characterized the proposal to impose mandatory CE as part of a larger initiative by the licensing board to bring Michigan’s licensure rules "into step" with those of other states. He said the current board has concluded that Michigan has, for years, lagged behind other states in its standards for licensure. Until recently, Michigan required a passing score on the national exam that was considerably lower than that of most other states. (The Board has now raised the passing score.) Dr. Haynes said he did not know why Michigan had been an outlier on licensure rules, but mentioned that the composition of the licensing board shifts over time, and that leadership was an important element in pursuing these initiatives. Dr. Haynes said he could not venture an estimate as to the time frame for either the public hearing or the establishment of the CE requirement. He doubted that the new regulations would be passed into law during this calendar year. He was uncertain as to how psychologists in Michigan would be notified that the proposal had been passed or that a hearing was being held. He said there would be "public notification" of the hearing, but he was uncertain as to how this would be accomplished. He expected that information about proposed CE requirements would reach psychologists through the various professional organizations. ARGUMENTS ADVANCED BY PROPONENTS Proponents of CE requirements for licensure advance a number of reasons for the necessity and desirability of such requirements. They argue that CE protects the public from psychologists who do little or nothing to maintain their knowledge and skills after gaining licensure. Loretta Polish, Ph.D., Chair of the MPA Licensing Committee observes, "The primary complaint brought against individual psychologists in Michigan is incompetence. Psychologists are people, and like all people, they may not continue their education unless they have to." CE requirements, says Dr. Polish, ensure that psychologists "keep learning about new and evolving knowledge" which, proponents hope, may reduce the frequency of such complaints. In addition, proponents argue, CE requirements for licensure benefit all psychologists by bringing people together to discuss new ideas and interact with professional colleagues. Such interactions, it is argued, also may have intangible but important results in the area of keeping otherwise isolated practitioners in step with the professional mainstream and may serve to open up blind-spots that would otherwise go unnoticed. A second major reason advanced by proponents of CE is that it will improve the mobility of Michigan psychologists. At present, psychologists who relocate to other states sometimes have difficulty in gaining licensure because of differences between Michigan’s requirements for licensure and those of other states. The initiative to bring Michigan’s licensure rules more into line with those of other states is reportedly being undertaken in part so that Michigan psychologists who want to relocate will face less difficulty gaining licensure in other states. A third major reason cited by proponents is the perception that CE is becoming accepted as a matter of course in other professions (in law, accounting, and education as well as health-care) and will soon be required in every state. Neither psychologists as a profession nor individual state licensing boards want to be seen as out of step with such a dominant trend. In every profession, there is pressure on the state to protect the public from incompetent or unscrupulous practitioners. Mandating CE has become the standard way of demonstrating that licensing boards and leaders in each profession are working to hold the members of that profession to high standards of practice. The Director of the APA’s Office of Continuing Professional Education, Joanne Linder-Crow, predicts that CE is here to stay. "The trend is for more, rather than fewer, states to require CE. The time to argue the issue has come and gone, and the focus now needs to be on developing quality programs with more emphasis on practice-oriented skills." THE IMPACT OF CONTINUING EDUCATION REQUIREMENTS Surprisingly, given the widespread and growing use of mandatory CE for members of the health-care professions, there has been almost no research on the effectiveness of such programs in accomplishing their stated aims. Dr. Linder-Crow explains, "It’s a bit of a dilemma. There is no information available on the impact of CE for psychologists" (for example, on the kinds or number of complaints brought against psychologists in states that have mandatory CE versus those that do not). "The APA Insurance Trust gives discounts to psychologists who participate in CE, but they don’t have the stats to back it up.... It’s very hard to measure the effectiveness of CE in psychology. If you did find an improvement, it would be difficult to distinguish how much was due to content and how much to the experience of interacting with colleagues that is part of CE programs…What most people end up saying is that it has to be helpful to have CE. It has to be better than not doing it." Jack Haynes, Ph.D., whose committee wrote the Michigan Board of Psychology proposal, echoed this view, saying that, while it probably could not be proved that CE makes people better psychologists, he believed it could be expected in the same way it could be expected that a person who does all of the reading in graduate courses will be a better psychologist than a person who only does half the reading. The exposure and stimulation psychologists experience from required CE, he argued, has to be better than the lack of such exposure and stimulation. Dr. Linder-Crow, who also sits on a subcommittee of the Association of State and Provincial Psychology Boards (ASPPB) working to standardize CE requirements (which now vary from state to state), noted that there is a need for research in this area, as seen by the increasing number of inquiries from government officials in states that do have CE requirements for licensure. "They say, what can you tell us about the impact of CE? And I tell the other members of my subcommittee that we can expect more and more questions of this kind. There is little information available on CE. At this point, for example, there is no clear rationale for requiring 10 or 20 or 50 CE credits per year. People say, Well, lawyers have X number, so why don’t we make it X for psychologists?" Although it takes no official position on the question of whether states should mandate CE, the APA is a central player in the CE business nationally. In an effort to ensure high standards for CE programs, the APA has set up a large bureaucracy. The task of this bureaucracy is to decide who will decide which programs qualify for CE credits and how many credits each qualifies for. Decisions about individual programs are made by official CE Sponsors, which are selected by a committee appointed by the APA Board of Educational Affairs. Sponsors may include state psychological associations, clinics, consulting firms, "specialty societies," or universities with APA-accredited doctoral programs in psychology. The APA has developed elaborate procedures and criteria to deal with the selection and continued approval of sponsors and with ensuring that programs offered for CE credit are evaluated by uniform national standards. For example, current guidelines require that sponsors must, among other things: (1) have a clearly identified administrator and a "mechanism for maintaining awareness of APA policies and principles"; (2) identify methods for determining psychologists’ learning needs, interests, and objectives and "solid assessment procedures" on which the selection of topics for programs is based; and (3) implement procedures for assessing participants’ satisfaction with programs and their degree of "perceived (self-report) and/or achieved (objective) learning relative to a program’s specific educational objectives." (For details, visit www.APA.org) ARGUMENTS ADVANCED BY CRITICS Criticisms of CE come from a variety of perspectives. One argument made is that, while CE may be necessary for medical professionals, it is not applicable to psychology because cutting edge technology and skills are not of the essence of what most psychologists need to know in order to do their work competently. What, these critics ask, is the body of knowledge that psychologists as a group need to keep up on? Unlike medicine, clinical work in psychology covers a broad range of theory and technique, and it would be impossible to "keep up" on all of it. In practice, few psychologists use more than one or two modalities, and familiarity with new skills or techniques is not a primary goal for many clinicians. A second set of arguments against mandatory CE concern the expense and inconvenience of the requirement. State governments can incur substantial costs in enforcing CE requirements. The APA runs a large bureaucracy to approve sponsors for CE programs. Organizations that are certified by the APA as official sponsors of CE programs become part of this bureaucracy and must find the money and personnel to keep up with its many and frequently changing rules and requirements. Under mandatory continuing education, organizations such as MSPP, which simply present programs as they always have, would have to comply with the required procedures to gain approved CE credits for these programs or face the possibility that they will lose their audiences to other groups that do. Individual practitioners can also expect to incur additional expense and inconvenience. The 1994 APA study included a survey which reported that, in states without mandatory CE, 29.3 percent of psychologists spent less than $500 on CE activities per license renewal cycle (in most states, as in Michigan, two years); in mandatory CE states the number spending less than $500 dropped to 19.9 percent. The report noted, however, that in CE and non-CE states alike, 81 percent of psychologists spent less than $2000 per license renewal cycle. In addition, practitioners will be required to keep documentation of their attendance at CE programs to be produced on demand. Is it reasonable, some critics ask, to cost so many people so much time, effort, and money? The answer, of course, depends upon one’s perception of what is gained. Estimates of the percentage of psychologists who, without mandatory CE, spend no time educating themselves vary widely, but most proponents of CE agree that one of its primary purposes is to reach this group. The 1994 APA study estimates the proportion at 25 to 30 percent. Joanne Linder-Crow, Director of the APA Office of Continuing Professional Education estimates the number at 2 to 3 percent. Whatever the numbers of psychologists who do nothing to continue their education, the interest of state governments in protecting the public from such persons is such, says Dr. Linder-Crow, that they are willing to impose substantial financial and paperwork requirements on the entire profession in order to target a small minority. Critics object that it is not possible to force people to behave professionally. Isn’t it more likely, they ask, that, under such a system, those who did not continue their education voluntarily will find ways to document their required CE hours without actually learning anything? A third set of concerns about mandatory CE come from those who say formalized CE requirements tend to limit and standardize the content of what professionals learn and discriminate against those who prefer to learn through private study or consultation rather than as members of audiences at programs. While some states allow some percentage of CE credits to come from private study, the vast majority of psychologists who are required to do so earn their CE credits by attending "approved" conferences. Critics ask whether it is wise to place any group in charge of deciding what constitutes acceptable continuing education for their colleagues. They argue that this trend has the potential to stifle diversity and lead to a deadening of debate that may be harmful to the long-term interests of the field of psychology. A fourth group of critics takes a functionalist view of the CE phenomenon, saying that arguments about the efficacy of CE miss the point, which is not educational but financial. This group observes that mandatory CE legislation has typically been strongly supported by state psychological associations because these organizations expect CE to make money for them. These are hard times for psychology, say the functionalists. Membership in professional organizations and attendance at professional conferences and programs is down nationwide. In this environment, state associations and some other groups see CE as a way of refilling their dwindling coffers. If, with the stroke of a pen, every psychologist in a state is suddenly required to attend the equivalent of two or three day-long conferences per year, at a cost of $70 to $200 each, clearly "non-dues income" for the organizations that put on such conferences stands to be greatly increased. The 1994 APA survey reported that 41 percent of psychologists from states that did not have mandatory CE reported that "CE programs were readily available with little travel of less than 100 miles one way." This number was considerably higher (59 percent) in states that had mandatory CE. Proponents see the increase in available programs as a positive development for the profession because of the increased variety of educational experiences open to psychologists. Functionalists argue that a significant element of the support for mandatory CE comes from groups anticipating that they will reap substantial profits purveying CE programs to a state-mandated captive audience. They add that, in some cases, state organizations have been disappointed to discover that the cost of compliance with bureaucratic guidelines offsets the new income generated by mandatory CE. WHAT’S AHEAD Continuing Education requirements are constantly evolving. While Michigan is just moving to require mandatory CE, other states have had such requirements for decades. One trend has been away from the enormous amount of paperwork involved in requiring all licensees to produce proof that they are meeting the requirements. To save administrative time and money, many states have moved toward an enforcement method based on sampling. Like the IRS, these licensing boards enforce compliance through the threat that anyone could be audited rather than the requirement that each psychologist show proof of compliance. A second trend is toward the standardization of CE criteria nationally. In his April 2000 president’s column APA president Patrick H. De Leon, Ph.D., urges psychologists to take a pro-active stance toward efforts to create national standards for practice and licensure in the health-care professions. Noting the rise of "telehealth" practices, which routinely cross state lines, De Leon compares psychologists’ licenses to drivers’ licenses, and argues that some form of national standards for licensure will be necessary if psychologists are going to compete successfully with other professions in the coming century. Licensing boards are working to standardize not only the number of mandatory CE credits, but the form in which they can be earned, the percentages of each cycle’s CE credits that must be approved by APA, and the content of what is taught. Joanne Linder-Crow, Director of the APA Office of Continuing Professional Education, notes a trend toward "skills-based" CE. Critics of the current system of CE requirements note that there is no evidence that CE improves professional practice. At present, CE can include so many different types of educational activities on so many different topics that a psychologist can, theoretically, fulfill CE requirements without learning anything that directly impacts his or her practice. Since the stated goal of CE requirements is to protect the public, there is pressure on licensing boards to show a direct connection between CE and improved practice. This may be done through an increased focus on requiring psychologists to get the bulk of their CE credits in areas that are directly related to their work. Clearly, how these more focused regulations are written and implemented will be matters of great moment to the future of the profession. |