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Excerpt
Since The Journal of ECT (JECT) is the official journal of the Association for Convulsive Therapy (ACT), I would like to address the issue of the ACT creating a “certification” in electroconvulsive therapy (ECT). Certification in ECT was proposed in a JECT editorial (Fink and Kellner, 1998). While the argument for ECT certification is persuasive, I believe that this move is premature and could become counterproductive to the practice of ECT in the United States.
The problem with ECT in the United States is not the absence of a certificate. The problem is not the lack of core educational standards, since these have been published by the American Psychiatric Association (APA) (1990). The problem is that ECT training in the United States is often not consistently up to these standards. Two years after the APA recommendations, Fink and Abrams (1992) critiqued the inadequate training in ECT in the United States as often failing to meet the minimum guidelines suggested by the APA Task Force. I have long been a proponent of some guidelines for an ECT curriculum, and currently have an article “in press” (1999). The APA Task Force on ECT guidelines (American Psychiatric Association, 1990) only provides the basic minimal knowledge about ECT and not the skills needed to be an independent practitioner. An argument raised by Fink and Kellner (1998) for certification by ACT is that the American Board of Psychiatry and Neurology (ABPN) does not specify a minimum ECT experience as they do for inpatient, outpatient, and child psychiatry. How can advanced skills be consistently taught if basics are lacking? There is a requirement for child psychiatry for everyone, not just child psychiatry fellows. Basic standards for ECT training in residency training programs can be enforced by ABPN. They cannot be enforced by ACT.
The time and effort expended on certification would be better spent in developing resources to help give adequate ECT training to residency training programs with limited access to ECT experts, developing minimal standards for postgraduate courses, and having a regular course at the APA Annual Meeting. If that is done, we are more likely to have hospitals adopt and enforce the credentialing recommendation that currently exist for ECT (American Psychiatric Association, 1990).
I object to the proposed process of certification. In due time, some manner of independent certification would be useful for ECT. This should not be undertaken by the ACT. According to the 1999 ACT Directory, the ACT has 356 American members, 48 foreign members, and 2 corporate members. The officers and board are primarily on the East Coast. While scientific “fact” should not be influenced by geography, there are issues not conclusively established (such as stimulus titration, electrode placement, treatment of post-ECT hypertension and tachycardia, etc.) that could be biased by geographic practices. There is a standard certifying body that ensures that Board Certification in a specific field is based on impartial criteria with an accepted standard. The American Board of Medical Specialties and the ABPN should fulfill that role for most ECT practitioners in the United States. Since they have not, addressing their objections and working within the established system is preferable to unilaterally offering an independent certification. Although change is time consuming, slowness helps to ensure that the change is substance based and not an idea that was hastily adopted. Recently the American Society of Clinical Psychopharmacology instituted a certifying examination for psychopharmacology. The response was mixed, but many viewed this quite negatively. Various cosmetic surgical societies have granted “certification” to a wide range of practitioners. Many in the public and the profession have viewed this as self serving.
